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This is the Full Title of a SessionJames Manz, M.D. CCDS-OConsultant in Spine & Neurological SurgeryMedical Director Mayo Enterprise Outpatient Clinical Documentation Integrity ProgramMayo Clinic Health SystemEau Claire, Wisconsin
Mayo Clinic in the Midwest ExperienceImplementation of an Outpatient Clinical Documentation Integrity (OCDI) Program
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Learning Objectives
• At the completion of this educational activity, the learner will be able to:
– Develop a structure to manage outpatient CDI in multiple physician practices across a geographically widespread organization
– Implement a back-end documentation review process
– Organize educational support and technology enhancement to assist in provider engagement
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Mayo Clinic in the Midwest Experience
• Strategy
• Structure
• EMR/EPIC enhancements
• Assessing Performance: Metrics
• Future
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Our Burning Platform to Start OCDI Program
• Significant financial impact related to a single ACA (HHS model) plan
• Impact affected two regions in one state
• External consultant identified we underperformed compared to the rest of the state
• Pilot to address started in mid 2017 (with uncoordinated efforts prior to that)
• Success of pilot used as foundation to expand to include all 5 regions in Mayo Clinic in the Midwest
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Our Burning Platform to Start OCDI Program
• Increasing number of contracts with payers that are risk based
– Currently involved in 27 risk based contracts
– Multiple models: HCC, HHS, CDPS and ACG
– Increasing risk exposure to performance with time
– Payers need to be price competitive—if they price themselves out of the market, we lose patient volumes
• Entered ACO (Basic Track) this summer
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Our Burning Platform to Start OCDI Program
• BPCI-A engagement at two of the five regional sites
– Inpatient/Outpatient Percutaneous Coronary Interventions
– Congestive Heart Failure
– Major Joint Replacement of the Lower Extremity
• Outpatient denials based on documentation and supporting codes
• Practice request on E&M, Transitional Care Management (TCM) and Chronic Care Management (CCM) coding education & assist
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Initial Scope of our Work: Ambulatory Office Setting
• Service lines most immediately impactful resided in primary care
• Highest volume of encounters tied to patients impacted by risk models
• Family Medicine>Internal Medicine>>Pediatrics
• Patients are paneled, so data could more readily be attributed (provider, location, and region)
• Population Health already engaged with ACO application and awareness of impact—a willing partner
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Not in Direct Scope of our Work
• Inpatient CDI/Coding
– Separate group and longer historic footprint across Enterprise
– Close working relationship
– Encoder flags conditions that are HCC
– In scope for CDI work, many that are not CC/MCC impact mortality metrics and hospital rankings in US News & World Report
– All coding staff trained in HCC risk adjusted coding
• Emergency Department—external contracted coding
• Observation hospital encounters
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OCDI Team
• Practice engagement
– Regional physician advisors
– Location Champions—additional admin time to support effort, bring performance metrics back to their locations
– Primary care providers—15 minute weekly commitment
• CDS/CDI front facing staff—at the elbow support
• Backend secondary coding review of risk based encounters—risk adjusted trained coders
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Goals
• Distill the volume of information into manageable pieces
• Focus on what is most impactful
• Educate provider staff on Mayo enhanced EPIC tools built to help in this space
• Establish a resource structure to help/support/educate
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EPIC/Payers/Other• Data• Webinars/CEU’s• Targeted education
Backend Reviews• Add/modify/remove
details• Targeted education
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Regional Champions
Region 1 17
Region 2 15
Region 3
16
Region 4
7
Region 5
8Provider
Champions
Total 63
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CDS/CDI Resource
Region 1
CDS/CDI 1
CDS/CDI 2
CDS/CDI 3
CDS/CDI 4
CDS/CDI 5
CDS/CDI 6
Region 2
CDS/CDI 1
CDS/CDI 2
CDS/CDI 3
CDS/CDI 4
CDS/CDI 5
CDS/CDI 6
Region 3
CDS/CDI 1
CDS/CDI 2
CDS/CDI 3
CDS/CDI 4
CDS/CDI 5
CDS/CDI 6
Region 4
CDS/CDI 1
CDS/CDI 2
CDS/CDI 3
CDS/CDI 4
CDS/CDI 5
CDS/CDI 6
Region 5*
CDS/CDI 1
CDS/CDI 2
CDS/CDI 3
Shared
Shared
Shared
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Primary Care Providers Per Region
Region 1 140
Region 2 134
Region 3
118
Region 4
125
Region 5
194Primary Care
Providers
Total 711
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CDS/CDI & Provider Touchpoint Meetings
• 15 minute weekly meeting (‘at the elbow’) Face to Face (F2F)
• Compliance tracked and reported to Primary Care Leadership
• Average number of providers covered per CDS/CDI: 22
• Customized EMR profile to mimic what providers ‘see’
• Established job description and work competency expectations
• Expected to achieve CCDS-O within 3 years
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CDS/CDI & Provider Touchpoint Meetings
• Core provider focused support:– EPIC functionality, tips & tricks, personalization to optimize work
– Pre-reviews for upcoming risk contract based encounters
• Re-capture of known ‘dropped conditions’/gaps
• Identification of previously documented but not coded (captured) risk opportunities
– Post-review feedback on codes added/modified/or removed on backend review
– Disease focus: Diabetes Problem List (PL) accuracy and clean up
– Documentation tips
– Personal performance metrics
– Use of OCDI SharePoint site
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OCDI Back End Coding Review
• Back end work queues stop qualifying risk impacted ambulatory encounters for secondary review
• Not E&M validation
• Assess accuracy of self selected codes by providers and opportunity for additional risk capture
• Code details of what was added, modified and/or removed recorded to identify opportunities to improve
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OCDI Back End Coding Review
• Filtering of high volume
– Service line inclusion: Primary Care, Oncology and Cardiology
– Focus on encounters with known dropped conditions/gaps
• Queues emptied at end of day—minimize accounts receivable
• Specific job description and expectations created
• Expected to obtain CRC or CCDS-O within 3 years
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Educational Support
• Monthly Provider Champion/OCDI Team Meeting
– Disease focus
– EPIC/EMR functionality, tips & tricks
– Metrics/performance review
– Expectation that champions bring information back to location at future department meeting—dispersion of information with consistent messaging
– Video taped & archived with slide decks on OCDI website (SharePoint)
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Educational Support
• Enterprise SharePoint OCDI Site
– Education calendar
• Monthly champion meetings
• Third party webinars (Optum, BCBS, Humana)
– Electronic references (PDF)
• Internal and third party disease focus and coding guideline references
• HEDIS (Healthcare Effectiveness Data & Information Set) and other quality measure guidelines
– Answers to questions from staff/providers are collated and housed on website under FAQ section
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Mayo OCDI SharePoint Site
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Mayo OCDI SharePoint Site
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Mayo OCDI SharePoint Site
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EMR Enhancements
• EPIC is our platform—anyone on EPIC will have some ability to adopt
• Mayo opted for own internal terminology (Mayo Clinic Problem List—MCPL) for diagnoses codes instead of Intelligent Medical Objects (IMO)
• That allowed us to adapt existing EPIC tools
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Visual Flag That Condition is Risk Adjusted
• MCPL terms mapped to an ICD-10-CM code with risk adjustment will include “(HCC)”
• Search results:
• Selection via Diagnoses Calculator:
• Problem List results:
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Visual Flag That Condition is Risk Adjusted
• Column indicates diagnosis is risk adjusted
• Opted to just display “HCC” and not category number or risk impact
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Diagnoses Calculator
• Designed to allow providers to choose generic and get specific
• EPIC functionality, but Mayo specific build
• Clinical ‘language’ can be used on decision lines to drive to ICD 10 CM Code/Description
• All can be found by typing ‘nos’ (trigger letters) in any of the diagnoses/problem list search windows
• Work from top down
• “Go to Green”—we force provider to complete, don’t allow unspecified laterality*
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Diagnoses Calculator
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“Go to Green”
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If you don’t know for sure…
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Prompt for Additional Pertinent Codes
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Smart Text: Poor Man’s Encoder
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Comorbidity Preference List
• Available to all providers—ambulatory or hospital setting
• Each condition triggers a Diagnoses Calculator
• Most have risk impact (CC, MCC, and/or HCC)
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Comorbidity Preference List
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Leverage Common Diagnoses/Speed Buttons
• Opportunity to improve what was originally selected by practice
• Often choices are symptoms and not conditions
• Easy to pick = high likelihood of being used
• Can be centrally built and launched across a defined service line
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HCC Code Review and Best Practice Advisory (BPA)
• Points to conditions that were either billed in the past and/or risk adjusted terms on the Problem List that haven’t been captured in current billing cycle (akin to dropped condition/gap)
• Is actionable—you can add diagnosis to encounter and/or PL, remove, resolve directly
• Conditions in acute categories (20/83) are excluded: respiratory arrest, stroke, acute renal failure, sepsis, etc.
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HCC Code Review and Best Practice Advisory (BPA)
• Indicator on provider patient list flags the encounter
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HCC Code Review and Best Practice Advisory (BPA)
• Repositioned (taken out of standard BPA location to be more in line with workflow)
• Highlighted to stand out, positioned between PL and Visit Diagnosis
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HCC Code Review and Best Practice Advisory (BPA)
• Customization is possible
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HCC Code Review and Best Practice Advisory (BPA)
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Smart Phrase to Document the “Magic Words”
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Smart Phrase to Document the “Magic Words”
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Assessing Performance
• Top HCC categories
• Diabetes Coding with & without chronic complication/month
• EPIC HCC Code Review BPA usage by month
• Gap (dropped condition) Closure/month
• Add/Remove or Modify percent, rolling 3 months
• Risk plan performance (quarterly)
• ACOPerformance information significantly lags efforts
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Assessing Productivity & Engagement
• Provider engagement
• Backend coding impact
• Risk queue coverage
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Impact
• Significant improvement in our ACA plan performance
– Team instrumental in condition validation for ACA RADV audit on 2017 billing year
• Commercial payer assessments show significant improvement across the board
• ACO data will bring further clarity, but expected to be significantly delayed
• Opportunity exists in office CPT/visit billing
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Future Direction
• Recent expansion into last region, increasing direct provider coverage to over 700
• Pilot projects within our destination practices (MCR, MCF and MCA)
• Move to targeted specialty practices (2020)
– Hematology/Oncology
– Cardiovascular Medicine
• Expansion into E&M/TCM/CCM encounter coding (2020)
– 3rd party tool used in conjunction with Compliance and Medicare Strategy Unit to ensure accuracy and minimize risk
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Future Direction
• Potential supplemental revenue stream through payer partnerships to offset staffing costs: Provider Assessment Form (PAF)
• Development of coordinated process with the practice for ‘dropped patients’ (patients with dropped conditions/gaps and no completed or scheduled appointments for the year)
– Practice ensures visit is secured, team supports with pre-review to help facilitate accurate condition reporting
– Use of Annual Wellness Visit (AWV) to encourage patient participation
– Future pro-active year round AWV initiative to minimize number of at risk patients remaining at end of year
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Future Direction
• Pilot Study of use of AI/NLP tool dedicated to this space
– Potential for end to end integration with current EPIC/billing systems
– Current pre-review and post-encounter review workflows fit well with the application
– Real time provider facing prompts about potential conditions and adequacy of documentation to support
– Ability for direct provider communication via Enterprise dictation platform with OCDI staff
– Limited currently to single risk model (HCC)
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Thank you. Questions?
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 of the program guide.
