1. 3 rd Annual Association of Clinical Documentation Improvement Specialists Conference

2. Kristen Geissler, MS, PT, CPHQ, MBA Associate Director, Navigant Consulting, Inc. CMS Outcome Indicators Methodology, Risk Adjustment, & Strategy

3. Medicare’s outcome indicators 30-day Mortality – Heart Failure – Pneumonia – Acute MI 30-day Readmission – Heart Failure – Pneumonia – Acute MI AHRQ PSI – PSI 4 – Death among surgical patients with treatable serious complications (also known as “failure to rescue”) – PSI 6 – Iatrogenic pneumothorax (adult) – PSI 14 – Postoperative wound dehiscence – PSI 15 – Accidental puncture or laceration – IQI 11 – Abdominal aortic aneurysm (AAA) mortality rate – IQI 19 – Hip fracture mortality rate

4. Why understand the outcome indicator methodology? Public hospital performance – Mortality and readmission resonate with the public Financial impact – Currently pay-to-report – Significant readmission measure impact in health reform proposals Clinical Documentation Improvement programs – Physician buy-in – Severity queries – Impact of present on admission

5. A word on risk adjustment What measures need to be risk adjusted? – Outcome measures (mortality, complications, readmissions) Adjusts for complexity of care and severity of illness What is the methodology? – Many different methodologies APR-DRGTM (3M) HealthgradesTM proprietary CMS mortality risk adjustment How is risk adjustment used? – Actual rate versus expected rate i.e. sicker patients would have a higher expected rate of mortality What’s the bottom line? – The more accurately the coding/claims data represents the severity of illness of the patient, the more accurately the risk adjustment methodology will be applied

6. Mortality Indicators

7. CMS mortality rate Only for the Medicare population 30-day mortality – Acute MI – Heart Failure – Pneumonia Exclusions – LOS ≤ 1 day and discharged alive and not AMA – Medicare hospice program admission on first day of admission or hospice within 12 months prior to admission – Discharge AMA (new exclusion for 2009) Multiple admissions – One admission is chosen at random for inclusion in the model

8. CMS mortality rate Risk adjustment – Uses information from the following Medicare claims: Hospital inpatient Hospital outpatient Physician office – May not include: Inpatient secondary conditions that are ‘not present on admission’ Measurement model uses data from July 2005 through June 2008

9. Risk-standardized mortality rate Ratio of predicted to expected mortalities x national unadjusted rate: – Predicted number of 30-day mortalities (hosp- specific intercept) – Expected number of mortalities (average intercept)

10. Mortality data on hospital compare

11. Distribution of 30-day mortality results Better than US National Rate No Different than US National Rate Worse than US National Rate AMI131281454 HF2133812163 PN2533934284

12. Mortality risk adjustment AMIHFPN Age over 65 Male History of PTCA History of CABG History of CHF History of AMI AMI Unstable angina Chronic atherosclerosis Cardiopulmonary-respiratory failure or shock Valvular or rheumatic heart disease Hypertension Stroke Cerebrovascular disease Renal failure COPD History of pneumonia From CMS Measure Technical Specifications on www.qualitynet.org accessed 2/1/10www.qualitynet.org

13. Mortality risk adjustment AMIHFPN Diabetes or DM complications Protein-calorie malnutrition Dementia or other specified brain disorders Hemiplegia, paraplegia, paralysis, functional disability Peripheral vascular disease Metastatic cancer or other major cancers Trauma in last year Major psychiatric disorders Chronic liver disease Severe hematological disorders Parkinson’s or Huntingdon’s Disease Lung fibrosis or other chronic lung disorders Iron deficiency or other unspecified anemias and blood disease Depression Seizure disorders or convulsions Asthma Vertebral fractures From CMS Measure Technical Specifications on www.qualitynet.org accessed 2/1/10www.qualitynet.org

14. Readmission Indicators

15. Readmission rate for select illnesses Only for the Medicare population 30-day readmissions for any cause – Acute MI – Heart Failure – Pneumonia Exclusions – Admissions for patients with in-hospital death – Admissions subsequently transferred to another acute care facility – Admissions who are discharged AMA – Admissions without at least 12 months pre-discharge and 30 days post- discharge enrollment in fee-for-service Medicare – Admissions with LOS > 1 year – Same day readmissions for the same condition to the same hospital – AMI only: admissions discharged alive on same day they are admitted

16. Readmission risk adjustment Risk adjustment – Uses information from the following Medicare claims for the 12 months prior to admission: Hospital inpatient Hospital outpatient Physician office – May not include: Inpatient secondary conditions that are ‘not present on admission’ Measurement model uses data from July 2005 through June 2008

17. Risk-standardized readmission rate Ratio of predicted to expected readmissions x national unadjusted rate: – Predicted number of 30-day readmissions (hosp-specific intercept) – Expected number of readmissions (average intercept)

18. Readmission data on hospital compare

19. Distribution of 30-day readmission results Better than US National Rate No Different than US National Rate Worse than US National Rate AMI36248852 HF1803854233 PN884199198

20. Readmission risk adjustment AMIHFPN Age over 65 Male Hx of PTCA Hx of CABG AMI Cardiorespiratory failure or shock Hx CHF Acute coronary syndrome Angina pectoris/old MI Coronary atherosclerosis Valvular or rheumatic heart disease Arrhythmias Other heart disorders Stroke Cerebrovascular disease Hemiplegia, paraplegia, paralysis, functional disability Vascular or circulatory disease From CMS Measure Technical Specifications on www.qualitynet.org accessed 2/1/10www.qualitynet.org

21. Readmission risk adjustment AMIHFPN Diabetes or DM Complications Renal failure, End-stage renal disease or dialysis COPD History of pneumonia Lung fibrosis or other chronic lung disorders Asthma Pleural effusion/pneumothorax; other lung disorders Severe hematological disorders Iron deficiency or other unspecified anemias and blood disease Dementia or other specified brain disorders Drug/alcohol abuse/dependence/psychosis Major psychiatric disorders Depression Other psychiatric disorders Metastatic cancer or acute leukemia Cancer From CMS Measure Technical Specifications on www.qualitynet.org accessed 2/1/10www.qualitynet.org

22. Readmission risk adjustment AMIHFPN Lung or other severe cancers Other major cancers Protein-calorie malnutrition Disorders of fluid/electrolyte/acid-base End stage liver disease Peptic ulcer, hemorrhage, other specified gastrointestinal disorders Other gastrointestinal disorders History of infection Septicemia/shock Nephritis Urinary tract infection Other urinary tract disorders Decubitus ulcer or chronic skin ulcer Vertebral fractures Other injuries From CMS Measure Technical Specifications on www.qualitynet.org accessed 2/1/10www.qualitynet.org

23. A word (or two) on present on admission Currently required for all Medicare diagnoses – May be required by your state or other payers Currently used for CMS Hospital Acquired Conditions (HACs) – No aggregate feedback to hospitals – No widespread accuracy feedback – Still very little focus nationwide

24. POA challenges Inconsistent and ineffective upfront training Very little feedback on accuracy Encoder limitations Early adoption of ‘internal policies’ difficult to change

25. Analysis of POA data POA Indicators Assigned to Every Diagnosis Code “Y”Diagnosis present at the time of order for inpatient admission “N”Diagnosis not present on admission (developed during hospital stay) “W”Provider unable to clinically determine whether condition was present on admission or not “U”Documentation insufficient to determine if condition is present on admission “1” (Medicare) or “E” Diagnosis exempt from POA reporting Note: In current Medicare policy, “W” is treated the same as “Y” and “U” is treated the same as “N.”

26. Final thoughts Documentation and coding will impact outcome measure risk adjustment May be future financial impact from risk- adjusted mortality and readmission Consider new or expanded query opportunities – All secondary conditions – Present on admission