Tuesday, 08 September 2015 22:46

VBP and Analytics in an ICD-10 World: Preparedness in the Eye of the Storm

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Most years, the nearing of the end of summer and the beginning of fall conjure up thoughts of back-to-school activities, all things pumpkin and apple, crisp air, and hayrides! For most in healthcare, however, especially those who work within health information management, quality, and revenue cycle roles, many of these thoughts haven’t even begun to surface. Nor is it likely that the normal fall activities will be embraced as heartily as in years past. Why? The change of seasons and all that it brings is just another reminder of one of the biggest changes that healthcare has seen in years: the advent of ICD-10 and all that it brings.

While arguably, there are individuals who remain under the assumption that ICD-10 is “just” a coding and health information concern, those in the aforementioned areas (and in many other realms in healthcare) know that this is simply not the case. This change brings no more of a “one-department” change than Y2K was an IT responsibility, or the HIPAA rules were and are a compliance responsibility. 

Yes, coding is in the eye of the storm, and as with any storm, the effects can be far-reaching. Attention now must be focused on those areas surrounding the eye of the storm.

As we all are aware, all hospitals that receive Medicare funding, which generally accounts for close to 60 percent of a hospital’s reimbursement, must submit certain proscribed core measures to the Centers for Medicare & Medicaid Services (CMS) to receive the Medicare annual payment update. The Joint Commission also requires the submission of core measures for accreditation and certain certifications (stroke, heart failure, etc.). One of the domains in value-based purchasing (VBP) is the submission of core measures. Keep in mind how patients are selected for inclusion or exclusion from core measures: through administrative data, commonly known as the uniform bill. Coding is in the eye of the storm, but core measures are in the eyewall! 

Taking this a step further, let’s look at the impact of ICD-10 on VBP beyond core measures. Value-based purchasing also includes the Hospital Readmission Reduction Program (HRRP) and the hospital-acquired conditions (HACs) domains. Both of these are “penalty only” and represent the potential for significant loss of revenue. Although there have been some impressive downward trends in both of these domains over the last two years, the need to proactively monitor and improve continues. 

Documentation integrity no doubt will play an even greater role during the ICD-10 transition. With the number of available code sets growing exponentially, accurate and timely documentation is of the essence in order to ensure the delivery of safe and cost-effective patient care. Documentation integrity and improvement interventions need to begin at the beginning: at the time of admission. Organizations still struggle with accurate documentation and thus coding of present-on-admission (POA) conditions. Failure to precisely document comorbid conditions can result in patient safety concerns as well as falsely increase the hospital’s HACs rate. In the presence of certain comorbid conditions, what would normally be classified as a HAC are excluded from the calculation, just as certain patients are excluded from core measure requirements. The importance and impact of a detailed review and documentation of comorbid conditions cannot be overemphasized! It is widely recognized that patients with comorbid conditions are at a greater risk for hospital-acquired conditions. During a performance improvement project at a multi-hospital system in the Mid-Atlantic, it was discovered that poor documentation and coding inaccuracies were greatly skewing the numbers of HACs. Through a cross-functional approach, however, the system successfully improved both patient care and the bottom line.

Accuracy of the date of admission carries a frequently overlooked potential for generating inaccurate reporting on readmission rates. Be certain that dates and times are accurate and consistent throughout the medical record. A discrepancy of just a few minutes or hours can trigger readmission penalties.

Just as with any other healthcare initiative, preparing and planning for ICD-10 requires a cross-functional approach and effort. Reimbursement from commercial payors is not the only revenue at risk. VBP, the Delivery System Reform Incentive Program, and state-based initiatives, all of which provide financial incentives and penalties, also represent revenue at risk. 

It is not too late to finalize (or build) your preparedness kit! Here are some essentials you will need:

  • Know your current and historical performance data:
    • Hospital-acquired conditions
    • Present-on-admission conditions
    • Readmission data
    • Core measure performance
    • Value-based purchasing performance
  • Know your patients:
    • Rate of comorbid conditions
    • Most frequent pairings of comorbid conditions
    • Most frequent types of HACs
    • Conditions with the highest readmission rates
    • Discharge disposition of those with high readmission rates
  • Know your physicians:
    • Readmission performance
    • Rate of complications
    • Rate of HACs
    • Discharge practices
  • Tighten up:
    • Denial appeals process
    • Use of inter-rater reliability for core measure consistency
    • Coding quality control practices
    • Data steward practices and control

As the date for the great transition draws nearer, focus on the horizon and look at the big picture. Whether you are in the eye of the storm or anywhere near it, with careful and strategic planning, you will weather the storm.

About the Author

Catherine Gorman-Klug has over 30 years of experience in healthcare. In addition to a varied clinical background, she has extensive experience in project design, implementation, and management. As director of the Quality Service Line for Nuance’s Quality Management Suite, she is responsible for product strategy for the Clintegrity 360|Quality Measures, Performance Analytics, and Narrative Search Solutions. This includes monitoring the regulatory horizon to ensure that current and future Clintegrity 360|Quality solutions are compliant with new and revised regulations, including but not limited to TJC, CMS, HIPAA, value-based purchasing, and the American Recovery and Reinvestment Act.

A frequent speaker, author, and blogger on quality and compliance activities, Cathy truly understands the challenges industry stakeholders face, and she uses her experience to help them meet the ever-increasing and changing regulatory and accreditation requirements. Prior to her role with Nuance, Cathy served as a corporate director of regulatory requirements, privacy, and data security for an integrated health system.

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Cathy, has over thirty years’ experience in healthcare. In addition to a varied clinical background, she has extensive experience in project design, implementation and management. As Director of the Quality Service Line for Nuance’s Quality Management Suite, she is responsible for product strategy for the Clintegrity 360 | Quality Measures, Performance Analytics and Narrative Search solutions This includes monitoring the regulatory horizon to ensure that current and future Clintegrity 360 | Quality solutions are compliant with new and revised regulations; including but not limited to TJC; CMS; HIPAA, value-based purchasing, the American Recovery and Reinvestment Act.

A frequent speaker, author and blogger on Quality and Compliance activities, Cathy truly understands the challenges industry stakeholders face, and uses her experience to help them meet the ever increasing and changing regulatory and accreditation requirements. Prior to her role with Nuance, Cathy served as a Corporate Director of Regulatory Requirements, Privacy and Data Security for an integrated health system.