Ready CDI teams for CMS’ proposed expansion of mandatory ortho episode payment models

by Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer

If your hospital resides in one of the 67 metropolitan statistical areas (MSA) required to participate in the Comprehensive Joint Replacement Model (CJR), you will also be required to participate in a new orthopedic payment model called SHFFT (surgical hip and femur fracture treatment) if an August 2 proposed rule is finalized. The impact? The following assigned MS-DRGs will no longer define hospital reimbursement:

• Major Joint Replacement or Reattachment of Lower Extremity (MS-DRGs 469, 470)
• Hip and Femur Procedures Except Major Joint (MS-DRGs 480, 481, 482)

MS-DRGs 469 and 470 are included in the CJR, which we have discussed in prior articles. Let’s take a look at the proposed SHFFT episode payment model (EPM), which involves the other three MS-DRGs, and see what role the CDI program can play as reimbursement shifts to episode-based payments.

Model overview

The episode of care defined for the SHFFT EPM begins with an admission to a participating hospital of a fee-for-service Medicare patient assigned MS-DRGs 480?482. This admission is referred to as the anchor hospitalization. The episode continues 90 days post-discharge from the hospital, and payments for all related Part A and Part B services are included in the episode payment bundle. CMS holds the hospital accountable for defined cost and quality outcomes during the episode and links reimbursement?which may consist of payment penalties and/or financial incentives?to outcome performance.

This is a mandatory EPM for hospitals already impacted by the CJR; the SHFFT model will apply to the same 67 geographic MSAs. The EPM is proposed to begin July 1, 2017, and will last for five years, ending in December 2021.

Cost outcomes

CMS will initially pay the hospital and all providers who bill for services during the episode using the usual fee-for-service models. Thus, the SHFFT EPM will not impact the revenue cycle at first. However, at the end of each performance period, which typically represents 12 months (January through December), CMS will compare or reconcile the actual costs with a preestablished "target price."

CMS will set target prices using an approach that will phase in a blended rate of hospital to regional costs. In recognition of the higher costs associated with discharges in MS-DRGs with an MCC or CC, CMS has developed an algorithm to adjust the target price for this subset of the patient population.

If the reconciliation process indicates that the costs to deliver services for the episode were higher than the target price, CMS will require repayment from the hospital. If, however, the costs to deliver care for the episode were lower than the target price, CMS will provide additional payments to the hospital for the provided services. To receive additional payments, however, performance for defined quality outcomes must meet or exceed established standards.

Quality-adjusted target price

To receive any earned financial incentives, the hospital must meet or exceed performance standards for established quality outcomes. CMS therefore adjusts the target price based on quality performance, referred to as the quality-adjusted target price.

The SHFFT EPM uses the exact same quality outcomes as those defined for the CJR:

• Patient experience. This is the HCAHPS measure also used in the Hospital Value-Based Purchasing Program (HVBP). The source of information for this measures is the HCAHPS survey.
• Patient-reported outcome data. As with the CJR, the hospital can collect and submit patient-reported data elements and at present will earn quality composite points for submitting the data. These data elements are collected both before and after the procedure and will be used by CMS to create a functional status measurement tool.
• THA/TKA complication rates. This is the Hospital-Level Risk Standardized Complication Rate (RSCR) following the THA/TKA measure. This measure already impacts financial performance under the HVBP. Like the CJR, performance for this measure is weighted the heaviest in the quality composite comprising 50% of the composite score.

Hospital (accountable party), collaborators, and Advanced Payment Models

The hospital is held accountable for episode cost and quality outcomes and all associated financial risks/rewards, even though a variety of providers deliver services and impact performance. As with the CJR, the hospital has been designated as the accountable party because CMS believes the hospital is best positioned to influence coordinated, efficient delivery of services from the patient’s initial hospitalization through recovery.

CMS permits the hospital to enter into collaborative arrangements with physicians and other providers to support and redesign care delivery across the episode and to share financial gains and/or losses. The proposed rule expands the list of collaborators defined in the previous CJR final rule to include other hospitals and Medicare Shared Savings Program accountable care organizations.

The proposed rule also provides an Advanced Payment Model (APM) track for the EPMs, an important step that will further incentivize collaborator participation.

CDI program opportunities

There are five key ways that clinical documentation and reported codes across the continuum impact SHFFT performance:

• Identification of patients included in the EPM. The assigned MS-DRG impacts which discharges are included in the cohort. As one example, consider a patient who would fall into the EPM (MS-DRGs 480?482) unless he or she has a bone biopsy. If reported, the bone biopsy would result in assignment of different MS-DRGs (477?479) and the discharge would not be included in the EPM.
• Establishment of target costs. The capture of the MCC and/or CC impacts establishment of the episode target price.
• Determination of related costs. The costs for hospital readmissions within the episode are included in episode costs if the readmissions are related. The assigned MS-DRG for the readmission determines whether the readmission is related.

The costs associated with Part B claims are included in episode costs if the services are related. The primary diagnosis for each visit determines whether the visit is related.

• Reported complications. Assignment of ICD codes for the following conditions are counted as complications when those conditions result in inpatient readmission:
• Complication risk adjustment. As with other hospital-centric measures such as risk-adjusted readmission and mortality rates, comorbidities reported for the 12 months prior to the anchor hospitalization are used to assess case-mix complexity. The CMS risk adjustment module uses defined comorbidity categories to identify conditions that impacted predicted rates of complications for the THA/TKA cohort.

The capture of at least one condition for each of the 28 comorbid categories over the 12-month period will strengthen risk adjustment and RSCR performance. RSCR performance contributes to 50% of the quality composite score, which, in turn, impacts the quality-adjusted target price.

Summary

Together the CJR and SHFFT models cover all surgical treatment options (hip arthroplasty and fixation) for Medicare beneficiaries with hip fractures. These MS-DRGs typically represent one of the largest inpatient surgical volumes for most short-term acute care hospitals.

As hospitals and collaborators assess and refine the management of patients to achieve or exceed the quality-adjusted target price, the data we submit on claims will be used to assess our performance. The CDI program in the inpatient and ambulatory setting must be positioned to promote and support the capture and reporting of impactful documentation.

Additional information on the proposed rule can be located at https://innovation.cms.gov/initiatives/epm.

Editor’s note

Newell is the director of CDI quality initiatives for Enjoin. Her team provides CDI programs with education, infrastructure design, and audits to successfully and sustainably address the transition to value-based payments. She has extensive operational and consulting expertise in coding and clinical documentation improvement, case management, and health information management. You can reach Newell at 704-931-8537 or [email protected].

Computer-assisted coding: Where are we today?

by Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP

In our computer-savvy tech world, the medical field has been notoriously slow to respond to newer technologies and applications of computer-assisted enhancements. However, in the HIM market, computer-assisted coding (CAC) has been touted to boost coding accuracy and productivity, in addition to being an important tool for the remote inpatient coder. 

Background

The term CAC denotes technology that automatically assigns codes from clinical documentation for a human to review, analyze, and use, according to the Journal of AHIMA.

Currently, there are a variety of methodologies, software, and integration interface applications that enable a CAC application to read text and assign codes. This type of software reads the information in a similar way to how a spell-check application works on a traditional computer. According to some users, data-driven documentation (e.g., documentation that is dictated or typed) is more accurately processed by the CAC software than documents that are scanned into the system for the software to use.  

CAC software works through recognition; it learns words and phrases, as well as learning the areas within a specific document where standardized words and phrases appear. CAC software also has the ability to discern the context or meaning of those words and phrases. The program then analyzes and predicts what the appropriate ICD-10-CM/PCS codes should be for the documented diagnoses and procedures it finds within the specified documents.

Software providing CAC functionality has been available for over 10 years, but it has come to the forefront of inpatient coding with the implementation of ICD-10-CM/PCS. CAC has allowed hospitals to reduce lag times and enhance DRGs while also finding missed MCC/CC diagnoses. The usage and integration of an electronic health record (EHR) has also played a role in better code assignment and usage for data analysis and outcomes.

It is yet to be shown whether CAC actually enhances a coder’s productivity rate. On the upside, CAC does give the coder a great place to start when working on a difficult inpatient record. CAC is now where we were more than 20 years ago when encoders were first introduced into the inpatient hospital marketplace for coding, abstracting, and data analysis.

Pros and cons of CAC

Due to the complexity of inpatient care records, clinical documentation, and the complexity of medical terms and abbreviations, many hospitals only use CAC together with intervention by human coders. However, the latest CAC software technology employs a type of natural language and syntax processing to compare, contrast, and extract specific medical terms from electronic data or typed text?so CAC stand-alone technology does exist. In studies conducted by AHIMA, though, the combination of a CAC with a coder/auditor has been proven to be just as good, or better than, a coder or CAC alone.

The biggest challenge CAC poses might be getting buy-in from the hospital coding and HIM staff. The HIM, coding, and clinical staff must all be a part of the changes and be on board with learning how to use this technology enhancement. In the past, there has been some uncertainty and fear related to CAC eliminating coders’ jobs. However, a good CAC solution in conjunction with HIM management allows coders to apply their critical thinking and analytical skills to create well-coded documentation of patients’ care. This, in turn, results in more accurate DRG assignment and reimbursement for the facility.

HIM and coding staff’s responsibility and role in the fiscal revenue stream will change as a result of CAC and similar technology. With this change must comes the acceptance that it takes both a human and a computer to successfully transform a CAC product into good financial outcomes and even better documentation.  

As coders will surely agree, the final code selection for inpatient records should be based upon coders’ knowledge of coding guidelines, clinical concepts, and compliance regulations. When working with CAC, the coder has the ability to agree with or to override codes that the software determines.  

Coders have the education to understand why a diagnosis or procedure should or should not be coded in a specific situation, and by using CAC, they can help the software learn to identify the importance of specific documentation and its relation to ICD-10-CM/PCS codes.

Many CAC vendors will try and sell their product based on the following list of features and benefits:

• Better medical coding accuracy
• Faster medical billing
• Greater coder satisfaction
• Identification of clinical documentation gaps
• Increased coder productivity
• More revenue from more detailed bills
• Return on investment?the CAC system quickly pays for itself

As we’ve said, it hasn’t been shown that CAC actually increases coders’ productivity. In reality, their productivity will probably stay the same, as a coder will still have to audit the information to determine whether the code generated by the software is correct. But in regard to the other CAC benefits on the above list, coder satisfaction should not be overlooked.

During AHIMA’s pilot testing of CAC software, the organization weighed in on some of the potential issues with using CAC software alone (with no human intervention). AHIMA noted that within specific areas of the pilot CAC testing in ICD-10, the coders did not accept 75% of the diagnosis codes presented, and they did not accept 90% of the procedure codes presented within the code sets. However, the information that the CAC software presented did give the coders a good starting reference to drill down to a more comprehensive diagnosis or procedure code.

Coders and CDI personnel will still need to be in charge of the following:

• Ensuring clinical documentation is complete and querying when appropriate
• Ensuring complete coding (e.g., for specificity)
• Ensuring correct sequencing of diagnosis and procedures
• Reviewing CCs/MCCs and DRG assignments with case complexity and severity

CAC, clinical documentation, EHR, and providers

Integration of clinical documentation from providers and physicians has always been a challenge, and combined with the implementation of ICD-10, it has presented a huge impetus for the adoption of CAC technology in hospital- and facility-based organizations.

Unfortunately, physicians still don’t provide thorough documentation, instead relying on CDI and coding staff to guide them. There has always been a disconnect in the language spoken by providers and the language spoken by coders. Physicians document in their comfort zone and fall back on terms such as "pneumonia," whereas a coder is looking for much more specificity. The integration of an EHR-based program and CAC for providers can lead to a good team relationship for both parties.Many CAC programs integrate well with hospital-based CDI programs and EHRs. These combination interfaces allow more real-time processing of possible code selection prior to the coder’s audit and review of the final code selection.

When the CAC software identifies these possibilities, there is an opportunity to identify and improve the DRGs with MCCs and CCs, as well as more quickly address areas for query and missed procedures or diagnoses.

Wrapping it all up

It is evident that coders and HIM professionals need to make a commitment to embrace change, which includes new technologies and integration of learning processes and opportunities. A hospital’s success depends on the coder acting as part of a team that will strive for successful outcomes for both the patient and the hospital.

Editor’s note

Webb is an E/M and procedure-based coding, compliance, data charge entry, and HIPAA privacy specialist with more than 20 years of experience. Her coding specialty is OB/GYN office/hospitalist services, maternal fetal medicine, OB/GYN oncology, urology, and general surgical coding. She can be reached via email at [email protected], and you can find current coding information on her blog at http://lori-lynnescodingcoachblog.blogspot.com. This article originally appeared on JustCoding, and opinions expressed are those of the author and do not represent HCPro or ACDIS.

Key attributes for coders moving forward amidst the 2017 coding guideline changes

by Laura Legg, RHIT, CCS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer

Resiliency is the ability to spring back or rebound. In sports, it’s one of the mental attributes a player must have. Coders are resilient: bouncing back from one change after another, deciding to code smarter and faster, and having the patience to do whatever is expected?even amid closing grace periods and guideline controversies.

The change to ICD-10 in October 2015, was a solid transition, and no one in healthcare was affected by it more than coders. The changes didn’t stop there. The coming months will again prove to be challenging for coders because of the new ICD-10 codes for both CM and PCS beginning October 1, 2016. Along with that, we’ll see the end of the CMS grace period on code specificity for Part B, and updated ICD-10-CM Official Coding Guidelines. Coders have a lot to learn this fall.

The Centers for Disease Control and Prevention published guidelines for discharges effective October 1, 2016, that have been approved by the four organizations that make up the Cooperating Parties for ICD-10-CM: the American Hospital Association, the American Health Information Management Association, CMS, and the National Center for Health Statistics.

The guidelines are available at www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf. In the linked document, the changes are indicated in bold type for easy identification. Below are some of the highlighted changes.

Excludes1

This guideline supports the interim advice published last fall. Here, the Cooperating Parties have given instructions that two conditions unrelated to each other represents an exception to the Excludes1 definition. If it is not clear whether the two conditions are related, coders must query the provider.

With

Under Section I.B.7 of the guidelines, "multiple coding for a single condition" clarification has been added for interpretation of the word "with."

The word "with" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms.

These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by this term in the classification, provider documentation must link the conditions in order to code them as related.

Code assignment and clinical criteria

Also under Section I, the Official Guidelines for Coding and Reporting tell us that the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

Coders are instructed to assign a diagnosis or procedure code according to physician documentation. Coders have been told in the past not to question the physician’s clinical judgment. This appears to be pretty simple until audits from outside the organization place more emphasis on the use of clinical criteria. This use of clinical criteria to assign reported codes is known as "clinical validation." When coders follow the official coding guideline instructing them that a code assignment is not based on clinical criteria used by the provider to establish the diagnosis, they will be caught between following the guideline as instructed and being presented with a claim denial based on the absence of clinical validation.

In today’s healthcare environment, it is essential that organizations face this issue head on and provide coders with guidance on how to solve the dilemma of a record that contains physician documentation but does not contain clinical validation. Clinical documentation improvement efforts to improve upon complex clinical condition documentation must continue to bring the coding and medical records together to allow coders to code correctly and avoid payer denials.

CMS must clarify the reason the Recovery Auditors are allowed to deny claims, whether auditors will bypass this official coding guideline, and how organizations can reconcile the discrepancy.

Laterality coding

This update clarifies that when a patient with a bilateral condition has surgical correction on both sides, the first side corrected is coded with the bilateral code. The second site is not coded using the bilateral code because the condition no longer exists on the corrected side. If the treatment on the first side did not completely resolve the condition, then the bilateral code is used.

Documentation for BMI, non-pressure ulcers, and pressure ulcer stages

Section I.B.14 says for body mass index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH Stroke Scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider. Dietitians often document the BMI, nurses often document pressure ulcer stages, and an emergency medical technician often documents the coma scale. Keep in mind the associated diagnosis must be documented by the patient’s provider. A query should be used to clarify any conflicting medical record documentation.

This guideline shows the addition of the coma scale and NIHSS to conditions where code assignment can be determined from clinicians who are not the patient’s provider. Many coders may not be familiar with the ­NIHSS?it is a 15-item neurologic examination used to evaluate the effect of acute cerebral infarction. The NIHSS evaluates:

• Levels of consciousness
• Language
• Neglect
• Visual field loss
• Extraocular movement
• Motor strength
• Ataxia
• Dysarthria
• Sensory loss

The NIHSS evaluation is often done by nursing staff and can help physicians quantify the severity of a stroke in the acute setting.

Zika virus infection

The official guidelines instruct coders to code only confirmed cases of the Zika virus with code A92.5 as documented by the provider. Note that this is an exception to the hospital inpatient guidelines. "Confirmation" does not require documentation of the type of test performed; the physician’s diagnostic statement that the condition is confirmed is sufficient. Documentation of "suspected," "possible," or "probable" Zika is not assigned to code A92.5.

Hypertensive crisis

A coding guideline has been added to instruct coders to assign a code from category I16 for hypertensive urgency, hypertensive emergency, or unspecified hypertensive crisis. This may call for some physician documentation education to make physicians aware that these more specific codes are available and can be used instead of documentation of hypertension without any further description.

Coma scale

In addition to using the coma scale codes (R40.2-) for traumatic brain injury codes, acute cerebrovascular disease codes, or sequelae of cerebrovascular disease codes, the coma scale may be used to assess the status of the central nervous system for other non-trauma conditions. Examples include monitoring patients in the ICU regardless of their medical condition.

Observation

One observation Z code category has been added for use when a newborn patient is being observed for a suspected condition that is ruled out. The new code category is Z05: encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out.

Newly added ICD-10 codes

CMS will implement an unprecedented number of new code changes October 1. A partial code freeze prevented regular updates for the last five years, resulting in the release of over 5,000 ICD-10 revisions on that date. The newest coding updates can be found at https://www.cms.gov/Medicare/Coding/ICD10/Latest_News.html.

The new ICD-10 codes come as we thaw out from the code freeze that has been in effect since October 1, 2011. Since that time, we have received only limited code updates to both the ICD-9 and ICD-10-CM/PCS code sets. Now, the long delay is over. ICD-10-CM changes include 1,928 diagnosis code changes with expanded code choices for atrial fibrillation, heart failure, diabetes mellitus Type 2, disorders of the breast, and pulmonary hypertension.

Extensive PCS updates are also being implemented. There are 3,651 new PCS codes, revised code titles, and a grand total of 75,625 valid codes with this update. It is important to note that 87% of the PCS code updates are in the cardiovascular system.

Following adoption of the new codes, review of coding accuracy will be needed. Any misconceptions or incorrect rationale should be recognized and communicated early to prevent ongoing or costly patterns from developing. Remember to ensure software updates are also in place and scheduled on time.

The new cardiovascular PCS codes include:

• Unique codes for unicondylar knee replacement
• Codes involving placement of an intravascular neurostimulator
• Expanded body part detail for the root operations Removal and Revision
• New codes in lower joint body system
• New codes for intracranial administration of substances such as Gliadel chemotherapy wafer using an open approach
• Addition of bifurcation qualifier to multiple root operation tables for all artery body part values
• Specific body part values for the thoracic aorta
• Specific table values to capture congenital cardiac procedures
• Unique device values for multiple intraluminal devices

Other PCS changes include:

• Donor organ perfusion
• Face transplant
• Hand transplant

The impact of the new codes will depend on what you do, so it’s important for hospitals to assess how the changes will affect them specifically. If you don’t deal with the areas where the codes have changed, the updates will be much easier than if your facility uses all the affected codes. Make sure the applicable codes are integrated into your internal applications and processes, while verifying that vendor products support the new codes. You don’t want to have claims rejected because not all of the new codes were incorporated.

Overall, there are moderate changes to the Official Guidelines for Coding and Reporting. The 2017 coding updates, however, are extensive and may seem overwhelming to some coders. The addition of over 10,000 codes after only one year of using ICD-10 will require coder resiliency to learn them all and understand how to apply them.

HCPro.com – Briefings on Coding Compliance Strategies