Building an Effective and Sustainable Ambulatory CDI ... · How to Develop a Business Case 22 Sample: Develop Your Business Case PPT Agenda (or contents if not presenting) • Executive

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Thinking Outside the Box: Building an Effective and Sustainable Ambulatory CDI Program

aka “How to Start an Ambulatory CDI Program Without

Falling Flat on Your Face”Rebecca Willcutt, BSN, RN, CCDS, CCS, CRCDirector, Clinical Documentation ImprovementCooper University Health CareCamden, New Jersey

Mary Rogers, CRC, CPC, COC, CCSSupervisor, Ambulatory Clinical Documentation Improvement Cooper University Health CareCamden, New Jersey

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• At the completion of this educational activity, the learner will be able to:

– Understand the key areas of focus for a beginning ambulatory CDIP

– Write a business plan to build the case for ambulatory CDIP, thus ensuring administrative support

– Learn 5 steps necessary to implement an ambulatory CDIP

– Customize physician education per data analysis in the ambulatory setting to engage physicians

Learning Objectives

2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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1.4 MillionOutpatient Visits

30K+ Admissions 7,000 Employees1,250 Nurses630 Physicians

Cooper University Health Care is the

leading academic health system in South

Jersey. Cooper includes South Jersey’s only

Level I trauma center (Cooper University

Hospital), a leading cancer center (MD

Anderson Cancer Center at Cooper), the only

Level II pediatric trauma center in the Delaware

Valley (Children’s Regional Hospital), one of

the largest physician groups in the region, four

urgent care centers, and more than 100

outpatient offices throughout South Jersey and

Pennsylvania.

2014

2015

2016

2017

2018

AC

CO

MP

LISH

ME

NT

S

2014 Inpatient Implementation• CMI shift 6.38%• 5 onsite CDSs/1 supervisor• By December: 2 remote CDSs/remote supervisor• Existing outpatient CDIP—E&M, RAI, education focused (3 FTEs)

2015• CMI shift 6.13%• ~30% reduction in PSIs & HACs• One director• 5 onsites/3 remotes

2016• CMI shift 7.51%• ~66% reduction in PSIs and HACs• 5 onsites/7 remotes• Peer‐reviewed publication• State presentations

2017• Expansion to ambulatory CDI/point of entry • Medicare CMI shift 4.73%• > 60% reduction PSIs and HACs• 4 onsites/9 remotes/2 ambulatory• National presentations • Peer‐reviewed publication

2018• Full expansion to ambulatory CDI/POE• 6 onsites/12 remotes/6 ambulatory teams• National presentations• Program data TBD


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High‐Level Basics

Medicare Advantage Organization (MAO) Payments

• Capitated payments are “risk adjusted” to account for the health status of each enrollee

• Risk scores measure relative risk

• Used to adjust payments for each beneficiary’s expected expenditures

• Based on an individual's diagnoses and demographics

• MAOs submit diagnosis data to CMS in order to receive these risk‐adjusted payments

• Diagnosis data received from providers

Risk‐Adjusted Payments – HCCs

• CMS has implemented the CMS Hierarchical Condition Category Model (“CMS‐HCC model”) that groups medical conditions that have similar costs of treatment into Hierarchical Condition Categories (HCCs) to establish a “risk score” for each enrollee

• CMS uses HCC codes to help determine how much care funding it will allocate for patients each year under Medicare Advantage (MA)

• Statistical model that measures incremental predicted costs associated with a person’s age, gender, and disease

• Developed using Medicare fee‐for‐service claims data

• The HCCs are the medical conditions that have been identified as those that most predictably affect the health status and healthcare costs of any individual patient

The Risk Adjustment Factor (RAF) score for an individual patient represents all of the Hierarchical Condition Categories (HCCs) that have been submitted for that person to CMS during the course of a calendar year. In a nutshell, compare it to the inpatient DRG.

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We all know the basics of high‐quality documentation should be the same in ALL

healthcare settings.


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We Understood the Need for Ambulatory CDIP

Expansion, but HOW?Ambulatory Challenges

• What the heck is an HCC? And a RAF score?

• Non‐existent HCC specific analysis and prioritization –how do we get reports?

• Sheer volume of OP cases• FTEs and ROI• Proving our case/impact• Issues related to timing: Is

concurrent review possible?• Where to even begin?•

…and then we realized we had already started

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Step One

Self‐Assessment: What Do You Already Have?


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Self‐Assessment

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Small Ambulatory Program• RAIs

Generation of requests for additional information6000 yearlyTied directly to revenue and RVUs

Structured Physician Education• E&M• Inpatient CDIP

COOPER ACO – 3000 lives• Accountable care organization refers to a legal entity composed of

a group of providers that assume responsibility to manage and coordinate care for a defined group of patients in an effective (high‐quality) and efficient (low‐cost) manner

Medical Director – Nicole Fox/Adam HolzbergOutpatient experienceInterest in informatics/EHRPracticing clinicianWell‐known & liked by medical staffA leader and great communicator

Partner w/ Compliance, Revenue Cycle, & Informatics

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We were already posting mandatoryclarifications, on the inpatient side, for HCCs:

• Morbid obesity • Type/acuity of heart failure• Diabetes w/acute/chronic conditions• Chronic COPD/bronchitis• All metastatic cancers along with primary site/current treatment• CKD stage

We can impact RAF scores on the inpatient side, but outpatient volume/capture is crucial.

We Already Had

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Step Two

What Are Your Metrics? What are you trying to accomplish, and how will you measure it?


What are your metrics? What is your focus?

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• HCC capture

• RAF scores

• Star ratings

• Improve outpatient quality scores

• Reduction of audit risks/denials

• Decrease in write-off volumes for lack of medical necessity for services provided

• E&M coding accuracy

• Decrease in cases rebilled or helddue to coding/billing edits

• Accurate reflection of patient acuity in data that impacts quality outcomes

• Increased patient care and satisfaction

Our 1st FocusWas the ACO

Did you know?It has been said that nearly 90% of all denials are PREVENTABLE. Denials will certainly be in your ambulatory CDI wheelhouse, but maybe not at

implementation.

Step Three

Reports Business Case


1) HCC capture report2) RAF scores past/present

We wanted the biggest

Capturing HCCs will capture AT LEAST 90% of the risk

adjustment

Step ThreeNumbers matter

How do you find the reports?• Customized reports from our data

scientist• From our ACO• From payers• From HIM• From billing/denials/appeals• From compliance

The Key to AdministrativeSupport Is Through a Business Plan and Reports

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Sample Report: Opportunity Identification by Provider


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Sample Report: Identifying Opportunity by Practice

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We Also Performed HCC Gap Analyses per Practices/Physicians

MORE SAMPLE REPORTS


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Sample Report Patient Distribution

48%

10%

4%

15%

2%

21%

Patient Volumes

Floyd

Ganti

<10 others

Green

Janakiramin

Khan

• Drs. Floyd, Ganti, Green, and Kahn see 94% of patients in Medicare Advantage Programs• Targeted education opportunities

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Sample: Drill Down on Data Demographics


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Other Gap Analyses Drill Downs

Data demographics

• Per male

• Per female

• Per payer

We identified opportunities to improve HCC Risk Gap …

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Opportunities to Improve Risk Gap


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How to Develop a Business Case

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Sample: Develop Your Business Case PPT

Agenda (or contents if not presenting)

• Executive summary

• Business need

– Statement

– Analysis

• Project overview

– Opinion of benefits and limitations

• Schedule or timeline

• Impact

• Financials

– Cost

– ROI

• Summary of options and recommendations

Project nameBusiness case

Month, day, yearPresented by


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Business Need

Statement: Make your case; make it urgent, convincing, and strong. No jargon, be interesting and concise.

Analysis: Restate the problem, underlying issues (use data).

Executive Summary

Problem (this is where you get attention)

Solutions (use as many rows as needed)

Choice Solution Benefit $Impact

1 List how you are going to solve

What are the benefits for this solution choice

Use ROI or NPV or IRR,

etc.

2 “ “ “

Or, just give a short summary. Remember, your summary is written last. You can’t write it without the proposal!

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Schedule or Timeline

• High‐level outline

• When to expect deliverables

Project Overview

• What is the scope or definition of the project? (general) • Is this a total or partial fix?• What is your goal?• Who are the stakeholders/players?• What systems does it affect?• Lay out a general concept.• What are the benefits? Only identify those you can

quantify:• Improve quality?• Save costs?• Generate revenue?• Improve patient care?

• Are there limitations or risks?


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FinancialsReturn on Investment

• ROI calculations (have at least 2 people check your numbers)

• Is this net or gross?

• Payback period

Cost (think of everything)

• FTE salary, benefits yearly (need a market analysis)

• Equipment

• Training

• Travel expenses (to clinics – know what your facility will reimburse)

• Real estate

Impact

Tangibles (only what you can quantify)

• Revenue

• Productivity savings

• Where did you get the numbers?

Intangibles

• Morale

• Improved patient satisfaction

• Improved physician satisfaction

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Summary

• Keep it brief

• Know your audience (C‐suite) – no silly graphics/pics

• Make it strong

• Briefly restate business need

• Identify pros and any cons

• Emphasize your ROI numbers

• State your recommendations and conclusions

Disclaimer: This is a general outline that I have developed based on research, experience, opinion, and outcomes. This outline was gleaned from dozens of sources that have been mixed and matched to fit my needs. It is a basic guideline only and may or may not contain all needed elements. You may customize this as you see fit. There is no guarantee that this plan will meet your needs or the needs or your organization. (Rebecca Willcutt)


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Step Four

Putting It All Together

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Clean Up Loose EndsMerge

Move Fast

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Who are you hiring?• Nurses?• Ambulatory coders? What certifications do

you require?• Create or rewrite job descriptions and get

them approved: Comp & HR• Use your salary market analysis to get

approval from compensation• What are their roles?• How much education is needed?

Merge ambulatory and inpatient CDI • Form steering committee and schedule

quarterly meetings (medical directors, compliance, HIM dir, CDIP dir/sup/rev cycle, pop health dir, VP informatics, etc.)

FTEs• Put out feelers before you write your plan • Once approved, IMMEDIATELY cast a wide

net for qualified FTEs. THEY ARE HARD TO FIND.* One headhunter described them as a “pink zebra.”

*It took us over a year to find a qualified surgical coding educator we could afford:

• Contacts• AAPC• ACDIS• AHIMA• Headhunters • Word of mouth

Just Do ItJust Do It


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Step Five

Education

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Team EducationPhysician Education

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3‐Day Onsite and Webex Training in Risk Adjustment Coding

Ambulatory CDI staffInpatient CDI staffInpatient coding Compliance

Physician Education

MANDATORY physician education per vendor(very high level)Onsite education• Group (specialties)• Shoulder to shoulder• HCC‐centric feedback via data mining, comparison reports• EHR best practice alert (BPA)• CUH HCC tip sheet

HCCsMEAT

COOPER’S WAYYours May Be Different


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Recap

1

SELF ASSESSMENT

2

METRICS

3

REPORTS &

BUSINESS PLAN

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PUT IT ALL TOGETHER

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EDUCATIONWHAT IS

ALREADY IN PLACE

WHAT ARE YOU TRYING TO ACHIEVE

THE BOTTOM LINE

CLEAN UP LOOSE ENDS

TEAMPHYSICIANCODING

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Thank you. Questions?

Rebecca Wilcutt ‐ Willcutt‐[email protected]

Mary Rogers ‐ Rogers‐[email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.


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Additional Information

...that may help you


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Misc Observations, Challenges, Unsolicited Advice, Etc.

ChallengesHow to identify where the HCC review need lies

Consider focusing only on HCC portion of RAF scoresHCC diagnosis capture

This is where the opportunities lieFilter out demographic and other constant RAF score metrics

Unlikely to change much – static information, not within provider’s controlReporting from MedicareReporting from MA plan carriersInternal system audits – check with your EMR vendor to see if they provide this type of applicationUnderstaffed?

Provider engagement – perpetual, ongoing, never‐ending, ad infinitum

QueriesIf none, need to create smooth, compliant workflow to addend notes/chartsFollow up – ticklers, emails, be gentle yet firm

Getting updated/additional information to the carrierCarrier/proprietary software?Charge corrections?

Outside Vendor assistanceWould it be cost effective or cost prohibitive ‐

for HCC captureReportingEducation


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Provider Engagement#1 ‐ Provider engagement – perpetual, ongoing, never‐ending, ad infinitum

Motivational (non‐monetary) approaches – think outside the boxLISTEN, acknowledge your provider’s concerns/complaints

Time constraintsAny shortcut availability to info he needsDon’t overwhelm with # of diagnosis – refer back to the # of categories

Pivot table prnDepend on audience personality

Stoic – just the facts ‘mamComic relief – make it funTechnical (millennials)Don’t badger – know your providers limitations, circle back if necessary

Are all documentation sources being reviewed? Outside specialists letters – scanned, very often overlooked later

Constantly remind provider – slate is wiped every yearBest to document appropriately for every patient encounterUpdated techniques and care require updated diagnosis information 1 to 1 correlation

Resources available to the provider:Available personnel?Available intranet resources?Articles, webinars, YouTube

Education – Use a Demonstration!Select a good sample documentation – use dx codes for that encounterFree Website RAF score – google for itRead back into patients chart – get the feel of your patientDoes provider’s documentation come short?

Opportunities for added specificityOpportunities for added acuityOpportunities to add missed HCC codes (next slide)

o HIVo Mental Healtho Morbid obesityo Amputationso Linking with “Due to”

Offer motivational support Look them in the eye “I hear you AND understand…” “You can do it!!” “I’m here to help!”

Don’t be stuck in the HCC‐CMS only ruto RX will need supporting diagnoses as well

Provide feedback to clinicianso Again, see engagement – re‐affirm, re‐educate, re‐support

Keep updated –o HCC changes are coming in 2019o 83 categories

4 new 56 Substance use disorder, mild, except alcohol and cannabis 58 reactive and unspecified psychosis 60 personality disorders 138 chronic kidney disease, MODERATE

some will be renamed 59 Major depressive, bipolar and paranoid disorders Discuss – encourage provider to appropriately document mental health diagnosis information to the highest

acuity. School shootings Random acts of violence Homelessness Lack of resources

o Healthcareo Nutritional food options

No PCP Language barrier

o Rising need for behavioral/mental health serviceso Health management resources for these patients are high


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Good Resources• https://www.acponline.org/system/files/documents/about_acp/chapters/md/kirsch

ner.pdf

• https://www.3mhisinsideangle.com/blog‐post/m‐e‐t‐even‐better‐well‐done/

• http://www.hccuniversity.com/

• https://www.medirevv.com/abcs‐of‐hcc‐coding‐webinar?hsCtaTracking=cb39d0eb‐6d5f‐4f1b‐8dd4‐e102578037b5%7Cd4a0ddd8‐43f7‐4a59‐aa03‐af8a90ed20a5

• QUICK REFERENCE INFORMATION: The ABCs of Providing the Annual Wellness Visit (AWV): http://www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNProducts/downloads/AWV_Chart_ICN905706.pdf

• https://www.premera.com/documents/035236.pdf

• https://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Monitoring‐Programs/Medicare‐Risk‐Adjustment‐Data‐Validation‐Program/Other‐Content‐Types/RADV‐Docs/Coders‐Guidance.pdf


Documents

Building an Effective and Sustainable Ambulatory CDI ... · How to Develop a Business Case 22 Sample: Develop Your Business Case PPT Agenda (or contents if not presenting) • Executive