Don’t Let Data Become a Monkey Wrench to Your Outpatient CDI … 6_2019... · Data Analytics: Saboteur or Conservator? 4 Why Now? •Increase in outpatient services –Outpatient

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Don’t Let Data Become a Monkey Wrench to Your Outpatient CDI Efforts

Laurie Benz, AS, CCS, CDIP, CPCOutpatient CDI Compliance and Education ManagerAMN Healthcare Revenue Cycle SolutionsTampa, FL

Christine PoleonDirector, Business Analytics & IntelligenceAMN Healthcare Revenue Cycle SolutionsTampa, FL

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Learning Objectives

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

• Develop skills in analyzing commercial and Medicare data to benefit outpatient CDI

• Discuss formulas for government and commercial payers to facilitate real‐time data analysis

• Discover how data can justify the creation of an outpatient CDI program

2019 Copyright, HCPro, a division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Data Analytics: Saboteur or Conservator?

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Why Now?

• Increase in outpatient services

– Outpatient surgery

– Outpatient treatment and diagnostics

– 2‐midnight rule – increase in observation vs. inpatient stays

• Quality, efficient, effective patient care

• Quality initiatives and incentives

• Interoperability

• Integrity of the patient record

– Patients’ clinical truth


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Why Now? (cont.)

Improper Payment Reason Improper Payment Rate Improper Payment Amount

Insufficient documentation 58% $18,328,000,000

Medical necessity 21.3% $6,730,800,000

No documentation 2.6% $821,600,000

Incorrect coding 11.9% $3,760,400,000

Other 6.3% $1,990,800,000

Totals 100% $31,600,000,000

• Centers for Medicare & Medicaid Services (CMS)

– 41 of 139 RAC‐approved topics are related to outpatient claims

– Over 31 billion dollars recouped in 2018

– 10.47 billion recouped from outpatient Part B providers

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Data Analytics: Challenges

1. Where do I get it?

2. Is the data quality—meaningful, relevant, accurate?

3. Who will analyze it?

4. Will our systems support data aggregation?

5. How will the organization perceive outcomes?

6. What if I have absolutely no idea?


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Data Analytics: Benefits

1. Fraud prevention

2. Cost savings

3. Increase or validation of revenue integrity

4. Better decision‐making

5. Increased efficiency

6. Identifies additional areas of opportunity

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Data Analytics: Additional Benefits

• Most promising career choice for 2019

– 56% increase in job openings over the last year

• 5,000+ posted in healthcare segment

• Quality outcomes

– Identifying trends, outliers

• Leads to improvements in documentation


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Simple First Steps

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Data Sources for Comparison

1. www.cms.gov

2. https://data.cms.gov

3. https://pepper.cbrpepper.org/Data

4. State resources such as https://oshpd.ca.gov

5. Group purchasing organizations

6. Commercial payers

7. Evidence‐based clinical guidelines applications

8. Your systems/software/applications

9. YOUR DATA


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Where to Find the Data: Step One

1. Step One ‐ Navigate to the CMS website: www.cms.gov

2. Step Two – Search for Hospital Outpatient PPS: Hospital Outpatient Prospective Payment System Rulemaking

3. Step Three – select 2019 NPRM OPPS Cost Statistics Files from the related links listed at the bottom of the page.

4. Step Four – Directs you to the following page: License for Use of Current Procedural Terminology. Click Accept: https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/HospitalOutpatientPPS/Addendum‐A‐and‐Addendum‐B‐Updates.html. Open or Save the zip file.

5. Step Five ‐ Save NPMR APC Cost Stats & NPRM CPT Cost Stats. You will pull national data totals from both.

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What to Do With It: Step Two

1. Add the total number of HCPCS per corresponding APC in the set

2. Divide each HCPCS/APC total into the set total that equals the % of total per HCPCS/APC

3. Apply the same formula using your facility data

4. Subtract % of MedPAR HCPCS from % of facility HCPCS


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Example Using ED Visits

HCPCS APC Payment Rate National Visits National Observed Hospital A VisitsHospital A Benchmark Variance

99281 5021 $67.63 464,854 2.66% 100 2.17% 0.49%

99282 5022 $122.79 1,085,669 6.22% 250 5.42% .8%

99283 5023 $215.83 4,595,084 26.31% 2000 43.39% ‐17.08%

99284 5024 $350.22 6,143,245 35.17% 1349 29.27% 5.9%

99285 5025 $513.07 5,178,213 29.65% 910 19.74% 9.91%

“Cost” of the variance = $159,525.00

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Comprehensive Observation Service Analysis

APC APC Description HCPCS HCPCS Description Comprehensive APC

Services

8011Comprehensive Observation Services 99281Emergency Department Visit, Self Limited Or Minor Problem 625 0.04%

8011Comprehensive Observation Services 99282Emergency Department Visit, Low To Moderately Severe Problem 1,601 0.12%

8011Comprehensive Observation Services 99283Emergency Department Visit, Moderately Severe Problem 23,566 1.70%

8011Comprehensive Observation Services 99284Emergency Department Visit, Problem Of High Severity 208,487 15.00%

8011Comprehensive Observation Services 99285

Emergency Department Visit, Problem With Significant Threat To Life Or Function 1,155,523 83.14%

Source: https://data.cms.gov/Medicare‐Outpatient/National‐Summary‐of‐Outpatient‐Hospital‐Charge‐Dat/vi9s‐8mez

National Observed


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Observation Conversion Analysis: Step Three

National OBS Conversion Rate Subject OBS Conversion Rate Conversion Variance Average OBS Payment Payment Variance

15.16% 8.68% ‐6.48% $2,348.33 ‐$701,480.51

$159,525.00 + $701,480.51 = “Cost” of the variance

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Observation to Inpatient Conversion Analysis: Step Four

# of Medicare Discharges # of Observation Claims OBS to IP

Assumption: MissedConversion Opportunity Average OBS Payment Payment Variance

2,497 417 14.3% 5% $9,551.00 ‐$1,78,785.45

$159,525.00 + $701,480.51 + $1,078,785.45 = “Cost” of the variance

$1,939,790.96


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How? Data Analysis

• Where?

– Accounts receivable reports

• Denial/takeback report

• Evaluation and management report

• Payer report by CPT®/APC

– Electronic health record

• Diagnosis reports

– Purchased data from data analysis vendors

– Published CMS data

• https://data.cms.gov

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Denial Report

• Helps to identify significant trends and opportunities

– Zero pays, partial pays, takebacks

Invoice Number

Date of Service Total Charge

Provider Name Total Pay

Total Adjustments Balance Rejection Reason Cause

A100819 06/05/2019 $172.00 Dr. X $0.00 $172.00 $0.00 Inadequate/ Insufficient documentation Documentation

A757214 08/08/2018 $478.00 Dr. A $0.00 $478.00 $0.00Maximum number of hours days exceeded for this provider to be paid Coding

16050396 08/14/2018 $23.00 Dr D. $0.00 $23.00 $0.00 Procedure is inconsistent for place of service Coding

A888412 02/05/2019 $370.00 Dr. A $0.00 $370.00 $0.00 Timely filing limit expired Billing


A325987 02/26/2019 $275.00 Dr C. $0.00 $275.00 $0.00 Timely filing limit expired Billing


A785214 11/19/2018 $430.00 Dr D. $0.00 $430.00 $0.00 Inadequate/ Insufficient documentation Documentation





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Identify the Root Cause

• In the case of Dr. X

– EHR template restrictions

– Incorrect template use

– Documentation gaps

– Template to charge mismatch

– Provider education opportunities

• Medical necessity = documented

clinical complexity

• Thoughts to paper

• Clinical considerations matter

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Evaluation and Management Data

National Bell Curve – Established Patient Family Medicine “Your Family Practice Data”

0

10

20

30

40

50

60

99211 99212 99213 99214 99215

Family Practice

0

10

20

30

40

50

60

99211 99212 99213 99214 99215

Family Practice


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Evaluation and Management Data (cont.)

• Identify outliers if they exist

– Perform a retrospective review on a reasonable percentage of outlier charts.

– Be sure to include a sample of charts for each provider.

– Validate medical necessity:

• Does your documentation meet medical necessity for the services provided to your patient based on the patient’s clinical picture at the time of the encounter?

• Does it reflect the true clinical picture of the patient and substantiate the reason for your assessment, treatment, and referrals?

– If the answer is yes to both of the questions above, there is no need to worry about recoupment. You can compliantly keep your money and rest assured that you are not a payer target.

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APC by Payer Data

APC Code Procedure Description

Total Medicare Payments

Total Number of Procedures

Average Payment per Procedure

Expected Payment Minus Coinsurance Variance Overall Loss

5491 Cataract removal with insertion of lens

$160,383 138 $1,162.00 $1,701 ($539) ($74,354.40)

– Review

– APC‐specific payer data for each chart in the sample

– Review documentation and diagnosis billed

– Identify gaps and root cause

– Remediate through collaboration with departments/providers involved

– Provide education as needed


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CPT by Payer Data

CPT Code Procedure Description

Total Medicare Payments

Total Number of Procedures

Average PaymentPer Procedure

Expected Payment Minus Coinsurance Variance Overall Loss

20610 Drain/inj joint/bursa w/o us

$74,383 1,586 $35.00 $72.24 ($37) ($59,062.64)

– Review

– CPT‐specific payer data for each chart in the sample

– Review documentation and diagnosis billed

– Identify gaps and root cause

– Remediate through collaboration with departments/providers involved

– Provide education as needed

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The Patient’s Clinical Truth

• Diagnosis specificity

– Supports medical necessity for services provided and ordered

– Provides accurate diagnosis statistics to payers and national agencies

– Enriches evidence‐based medicine clinical outcomes

– Accurately reflects the complexity of a patient’s complete clinical picture

– Reflects accurate risk adjustment factors for your patient population

– Promotes patient safety

– Reduces healthcare costs


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Diagnosis Data

• Diagnosis report reflects the most utilized diagnoses for your practice

– Identify opportunities based on lack of specificity related to uncaptured medical necessity

• Heart failure

• Pain, unspecified

• Anemia

• History of vs. active disease

• Alcohol or substance use vs. abuse

• Depression and anxiety

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Diagnosis Data (cont.)

Patient Demographics Diagnoses Documented Clinically Verified Specified Diagnoses

FemaleDescription ICD‐10‐CM Description ICD‐10‐CM

57 years old Diabetes E11.9 Diabetes w/ neuropathy E11.40

Lives in own home Neuropathy G62.9 Rheumatic heart failure I09.81

Heart disease I51.9

Calculated risk factor 1.418 4.338

• Where is your ROI?

– Every unspecified or missed diagnosis holds an opportunity—HCC


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Diagnosis Data (cont.)

E/M Level

Medical Decision‐Making

Diagnosis Medical Necessity Met?

Complete Clinical Picture Through Specified Diagnoses

Medical Necessity Met?

99212 Straightforward J02.9 Pharyngitis Yes

99213 Low complexity J02.9 Pharyngitis Maybe J06.0 Acute laryngopharyngitis Yes

99214 Moderate complexity J02.9 Pharyngitis No B00.2 Herpesviral gingivostomatitis and pharyngotonsillitis

Yes

99215 High complexity J02.9 Pharyngitis No B20 HIV Yes

B370 Candidal stomatitis

• Diagnosis specificity also illustrates the medical necessity for the level of service provided

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Data Goals

• Every healthcare provider’s goals are the same

– Uphold the integrity of the patient’s clinical record

– Quality, cost‐effective care

– Correct compliant reimbursement

• Don’t let the data be your monkey wrench

– Let it be your guide


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References

• https://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Monitoring‐Programs/Medicare‐FFS‐Compliance‐Programs/CERT/Downloads/2018MedicareFFSSuplementalImproperPaymentData.pdf

• https://data.cms.gov

• https://blog.linkedin.com/2019/january/10/linkedins‐most‐promising‐jobs‐of‐2019

• https://www.nejm.org/doi/full/10.1056/NEJMp1800732

• https://cms.gov

• https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/HospitalOutpatientPPS/Addendum‐A‐and‐Addendum‐B‐Updates.html

• https://data.cms.gov/Medicare‐Outpatient/National‐Summary‐of‐Outpatient‐Hospital‐Charge‐Dat/vi9s‐8mez

• https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/HospitalOutpatientPPS/Hospital‐Outpatient‐Regulations‐and‐Notices‐Items/CMS‐1678‐FC.html

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Thank you. Questions?

[email protected]@amnhealthcare.com

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.


Don’t Let Data Become a Monkey Wrench to Your Outpatient CDI … 6_2019... · Data Analytics: Saboteur or Conservator? 4 Why Now? •Increase in outpatient services –Outpatient

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