AHIMA Presentation

NATIONAL CC/MCC CAPTURE RATE & CASE MIX INDEX TRENDS Using Data to Drive Focused Audits and Education for Optimal Reimbursement

Sandra Brewton, RHIT, CCS, CICA, CHCA, CPC AHIMA-Approved ICD-10-CM/PCS Trainer

Maureen Matthews, BS, UC Davis Director of Business Development

Senior Healthcare Consultant Panacea Healthcare Solutions

Panacea Healthcare Solutions

Today’s Presenters

Maureen Matthews, B.S., UC Davis

Sandy Brewton, RHIT, CCS, CICA, CPC

Director of Business Development; Panacea Healthcare Solutions

Senior Healthcare Consultant; Panacea Healthcare Solutions

Maureen, has been working in healthcare since 1992. She started her career as a Director of Managed Care working for both non-profit health systems and non-profit payors. Later she moved to the vendor community as a Director of Business Development. She leverages her real-world healthcare experience to deliver top tier solutions for her clients in Health Information and Compliance Departments.

Sandy Brewton brings 25 years of experience in Health Information Management. Sandy offers expertise in inpatient, outpatient and professional services record audits, including review and validation of MS-DRG assignment and quality of physician documentation; coder and provider training and education to improve documentation quality and clarify code assignment; and recommendations for medical records operations and instructing facility staff on ICD-10-CM/PCS, and CPT coding guidelines. Sandy provides additional expertise in multispecialty outpatient surgery coding and pediatrics.

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Goals/Objectives ▪ Learn industry performance trends after implementation of ICD-10 • How these trends can identify favorable and unfavorable payment trend groups

▪ Understand the importance of capturing your CC/MCCs now and in the future ▪ Learn how this data can drive focused audits and education and the potential benefits to improve your coding, documentation and financial position

© 2019 Panacea Healthcare Solutions

© 2019 Panacea Healthcare Solutions, Inc.

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NATIONAL CC/MCC STUDY National and Regional CC/MCC & CMI Trends

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Goals of the Study ▪ Determine how the industry is performing overall since the implementation of ICD-10 and subsequently ▪ How individual health systems are trending and comparing to the national benchmarks ▪ Find out if there is continued opportunity in coding, documentation, and financial improvement ▪ Create benchmarks ▪ Provide reports

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Methodology 1. Study is based on Medicare claims data from October 1, 2015 through September 30, 2017 2. Analyzed data from 4,153 U.S. Hospitals 3. 195 DRG groups – both doublets and triplets (example: W/0 CC, W/CC, W/MCC)

4. Use standard CC/MCC capture rate calculations for all DRG doublets and triplets.

5. Assumed the data from CMS was correct

METHODOLOGY

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Overview ▪ Changes in healthcare, expected case-mix indices to increase year over year ▪ ICD-10 required greater specificity beginning Oct 1, 2015 ▪ Healthcare industry feared it would see decreases in case-mix indices and payments ▪ Fears did not play out.

Table 1: Hospital Operating Revenues and Margins Operating Revenue Increase 6%

Margin Decrease 3.5% to 2.7%

2015 - 2016

Table 1: Moody’s Investor Services, Not-For-Profit and Public Hospitals, 2017

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Nationwide Results – All DRG Groups Nationwide CC/MCC Capture Rate Change

Table 1

Across all groups case-mix indices have seen a 2.5% increase

Table 2

During the same period the weighted average CC/MCC capture rate for all DRG groups has seen an overall increase 1.3%

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Geographic Results Figure 5, trends by state tell a much different story

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Sample Status Results

© 2019 Panacea Healthcare Solutions

© 2019 Panacea Healthcare Solutions, Inc.

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Top Favorable Payment Trend Groups

Table 3

In Table 3 we can see the top five DRG groups where payment levels increased since October 1, 2015.

Heart Failure & Shock

$192,450,588

Chronic Obstructive Pulmonary Disease

$ 47,341,683

Circulatory Disorders except AMO, W CARD CATH

$ 20,352,283

PERC Cardiovasc PROC W Drug-Eluting Stent

$ 17,716,572

G.I. Hemorrhage

$ 12,413,736

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Top Unfavorable Payment Trend Groups

Table 4

Table 4, illustrates the top five MS-DRG groups realizing both case-mix and CC/MCC capture rate declines.

Septicemia or Severe Sepsis W/O MV>96 hours

($32,460,984)

Other Major Cardiovascular Procedures

($13,160,649)

Renal Failure

($12,995,926)

Stomach, Esophageal &Duodenal Procedures

($ 9,918,980)

Major Small & Large Bowl Procedures

($ 8,716,970)

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Opportunity Found?

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At Risk?

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Focused vs Random Audits… Is One Better Than the Other?

Audits: Focused or Random?

▪ Both are beneficial ▪ Random audits • Used for coder benchmarks - Not looking for specific problem areas

- Overall coding accuracy

▪ Focused audits • Not used for coder benchmarks - Looking for specific opportunities or high audit risk areas >

Based on data, denials, change in financials, etc.

© 2019 Panacea Healthcare Solutions

© 2019 Panacea Healthcare Solutions, Inc.

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Benefits and Challenges of Random Audits ▪ Coding benchmarks • Get overall accuracy rates by coder • Track coder accuracy rates quarterly/semi-annually/annually

▪ Coding team • Can show strengths • Can show weaknesses • Can result in education focus for team

▪ Accuracy rates • Often are high - May not be a true indicator of accuracy >

False security?

© 2019 Panacea Healthcare Solutions

© 2019 Panacea Healthcare Solutions, Inc.

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Benefits and Challenges of Focused Audits ▪ Reveals suspected problem areas • Denials • Changes in financials • CC/MCC capture rates

▪ Results in focused education • For coders, physicians and CDI

▪ Accuracy rates often low when problems confirmed ▪ Can I really review ALL my claims?

• Difficult to review ALL claims in a given period - Resource intensive Software. Consulting. Education. Results.

© 2019 Panacea Healthcare Solutions, Inc.

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CLIENT CASE STUDY Technology, Data and Focused Audits

Houston, We Have A Problem ▪ CFO and CMO noticed potential problem • Problematic queries - Provider complaints >

Unnecessary

>

Confusing

• Potential coding issues: - CHF, COPD, ARF, Sepsis, Malnutrition

▪ Random audits were fine ▪ Needed focused review • Were there problems as suspected?

Software. Consulting. Education. Results.

© 2019 Panacea Healthcare Solutions, Inc.

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Bring On the Technology ▪ Proprietary software • Custom rules/selection criteria • Analyzed 100% of claims in minutes

▪ Wrote rules w/parameters • Specific to areas of concern

▪ Ran rules • Analyzed most recent 6 months of data

▪ Selected 100 claims with highest risk/opportunity • Performed focused record and query audit Software. Consulting. Education. Results.

© 2019 Panacea Healthcare Solutions, Inc.

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Focused Audit – What Happened?

▪ Suspicions Confirmed • Combination of coding errors and documentation issues

▪ Accuracy rate standard: 95% Total Reviewed

Changes Recommended

Overall Accuracy %

MS-DRG

100

25

75%

Diagnosis Codes

482

86

82%

Procedure Codes

49

14

73%

▪ 100% of queries found to be leading/non-compliant Software. Consulting. Education. Results.

© 2019 Panacea Healthcare Solutions, Inc.

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What Next?

▪ Coder education • Customized, in person

▪ Meeting with physician advisor • Documentation improvement areas discussed • Plan implemented

▪ Follow-up audit in 6 months • Review same areas for improvement

Software. Consulting. Education. Results.

© 2019 Panacea Healthcare Solutions, Inc.

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Follow-up Focused Audit – Improvement?

▪ Improvement Realized on follow-up focused audit

Total Reviewed

Overall Accuracy %

Total Reviewed

Overall Accuracy %

Year 1

Year 1

Year 2

Year 2

MS-DRG

100

75%

100

93%

Diagnosis Codes

482

82%

318

97%

Procedure Codes

49

73%

75

96%

▪ 100% of queries found to be compliant

Software. Consulting. Education. Results.

© 2019 Panacea Healthcare Solutions, Inc.

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IPPS FY 2020 Dodged a Bullet……..(or did we)?

WHEW! ▪ Good News: • Proposed CC and MCC Deletions • Abandoned

▪ Bad News: • Proposed CC and MCC Deletions FY 2020 • Revisited for FY 2021

▪ Understand your CC/MCC capture rate • Opportunities • Risks • Control what you can Software. Consulting. Education. Results.

© 2019 Panacea Healthcare Solutions, Inc.

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Prepare for 2021 and Beyond ▪ Find your weak spots • Control what you can • Payers/external auditors are looking for them

▪ Know your CC/MCC capture rate • Compare to your peers

▪ Focused audits • Start with weakest areas identified

▪ Educate and develop staff Software. Consulting. Education. Results.

© 2019 Panacea Healthcare Solutions, Inc.

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Leverage Technology - CLAIMSauditor® I10 Focus Module

Software. Consulting. Education. Results.

© 2019 Panacea Healthcare Solutions, Inc.

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Leverage Technology –CLAIMSauditor I10 Focus Module

Software. Consulting. Education. Results.

© 2019 Panacea Healthcare Solutions, Inc.

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Leverage Technology – CLAIMSauditor I10 Focus Module

Software. Consulting. Education. Results.

© 2019 Panacea Healthcare Solutions, Inc.

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EDUCATION PLATFORMS Industry Experts for Enterprise Coding Education

Types of Education ▪ Onsite • In-person - Presentations - Interactive learning - Mentoring

▪ Webinars • Large or small groups

▪ Online • Assessments • Continuing Education • Development – New Coder, OP to IP, IP to Auditor Software. Consulting. Education. Results.

© 2019 Panacea Healthcare Solutions, Inc.

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Programs and Services - Education Coder Assessments:

CM, PCS, CPT®, IR, CARD, DRG/APR, E&M, Custom and Custom Pre-employment Assessments

Continuing Education for AHIMA and AAPC CEUs: ICD-10-CM Refresher: 10 CEUs CPT Refresher: 13 CEUs ICD-10-PCS Refresher: 11 CEUs DRG Refresher: 3 CEUs Annual Code Updates

New Coder: 40 CEUs (CPC or CCA) Uses 3Mencoder Coding Practice Tool: ED, SDS, IP, Custom New Biller: NHA, CBCS Exam

Applied PCS with Advanced Biomedicals for OP to IP: 40 CEUs IP Auditing: used in AHIMA Auditing Apprenticeship and HFMA CICA Certification Clinical Documentation Integrity Module: 30 hours, Physician Documentation, Queries, and Clinical Indicators

Specialty: IR, CARD, DX/TX EP, CRM, Ortho, Ophth, OB/GYN, Neuro, Rad Onc, Med Onc, Gen Surg, Uro, GI, Anesth, etc.

E&M Services for the Enterprise: Understanding Evaluation & Management Common Outpatient Procedures for Primary Care Preventive Medicine Mastering E & M Modifiers

HCC’s

Other: Incident To/Split Shared Services, Copy Paste, Auditing Strategies in working with Providers, E&M Basics, Transitional Care, Special Roles, Mastering M © 2019 Panacea Healthcare Solutions, Inc.

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Documentation Integrity Module – IP Auditing

Software. Consulting. Education. Results.

© 2019 Panacea Healthcare Solutions, Inc.

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RECOMMENDATIONS FOR 2020 Going Forward Into FY 2020

Top 10 DRG Categories With Potential Risk TOTAL CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES

025 - CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC 026 - CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC 027 - CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC

TOTAL SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS

871 - SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC 872 - SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC

TOTAL CELLULITIS

602 - CELLULITIS W MCC 603 - CELLULITIS W/O MCC

TOTAL MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES

640 - MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC 641 - MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W/O MCC

TOTAL 252 - OTHER VASCULAR PROCEDURES W MCC OTHER VASCULAR PROCEDURES 253 - OTHER VASCULAR PROCEDURES W CC 254 - OTHER VASCULAR PROCEDURES W/O CC/MCC

Software. Consulting. Education. Results.

© 2019 Panacea Healthcare Solutions, Inc.

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Top 10 DRG Categories With Potential Risk TOTAL 329 - MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC MAJOR SMALL & LARGE BOWEL PROCEDURES 330 - MAJOR SMALL & LARGE BOWEL PROCEDURES W CC 331 - MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC

TOTAL 308 - CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS 309 - CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC 310 - CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC

TOTAL 377 - G.I. HEMORRHAGE W MCC G.I. HEMORRHAGE 378 - G.I. HEMORRHAGE W CC 379 - G.I. HEMORRHAGE W/O CC/MCC

TOTAL 682 - RENAL FAILURE W MCC RENAL FAILURE 683 - RENAL FAILURE W CC 684 - RENAL FAILURE W/O CC/MCC

TOTAL 064 - INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION

065 - INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS 066 - INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC

Software. Consulting. Education. Results.

© 2019 Panacea Healthcare Solutions, Inc.

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Our Recommendations ▪ CC/MCC capture • Know your rate – get your 2018 CC/MCC report today - Compare to your peers/nation

▪ Use technology • Such as CLAIMSauditor – I-10 Focus Audit Module - Analyze 100% of your claims >

Leaves no stone unturned

▪ Focused audits

▪ Focused education Software. Consulting. Education. Results.

© 2019 Panacea Healthcare Solutions, Inc.

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To learn more or speak with a sales representative:

Office: (866) 926-5933 contact@panaceainc.com