Getting their Money’s Worth…Value-Based Purchasing

Value-based purchasing further emphasizes the ripple effect and spider web of CDI, HIM and Quality. Everyone “knows” about value-based purchasing, but what is it comprised of?

Value-based purchasing (VBP) is both a broad and narrow quality measurement tool. Broadly defined, pay for performance (P4P)/ VBP is payer-developed metrics to measure value compared to reimbursement given. Two examples are accountable care organizations (ACOs) and bundled payments. A narrow definition is a program mandated by the Affordable Care Act of 2010 and administered by CMS. VBP has been in development for almost 10 years but was formally introduced for FY 2013. Through the Medicare program, incentive payments are made to hospitals based on either how well they perform or improve against their own baseline on each domain comprising VBP. There are four domains: clinical process of care, patient experience of care, outcome (FY 2014 forward) and efficiency (FY 2015 forward). Each domain is assigned an associated weight. For example, in FY 2015 clinical process is 20 percent of the total VBP score, patient experience is 30 percent, outcome is weighted at 30 percent and efficiency rounds it out at 20 percent. Continue reading

Will 2014 be a Year to Remember for Outpatient CDI?

The other day, I was thinking back to the year 1987: Ronald Reagan was President, the New York Giants won the Super Bowl and the Minnesota Twins won the World Series. Michael Jackson released his third album, Bad, and “Walk Like an Egyptian” by the Bangles was the number one hit on The Billboard Top 100.

1987 was also the beginning of an important initiative in healthcare and health information management. This was the year that 3M created its inpatient clinical documentation improvement (CDI) program. Continue reading

E&M Guidelines: HPI and Chronic Conditions

Last month, I blogged about the History of Present Illness (HPI) portion of an E&M note. The HPI section details the specifics of why the patient is seeing their physician. Prior to that, I wrote about the two sets of E&M guidelines, specifically the different exams within those guidelines to guide physicians and/or coders to select a level of care provided during that visit. This month, I’d like to dig into the point at which these two sets of guidelines converge: chronic conditions.

The 1995 E&M documentation guidelines stipulate that to support the higher levels of care, a provider must document four or more elements of the HPI. The 1997 E&M documentation guidelines added a chronic conditions option. These guidelines state that a provider could document the status of three or more chronic conditions rather than four or more elements of the HPI. Continue reading

Is Value-Based Purchasing Working? Should We Make it a Game?

Value-based purchasing (VBP), a program authorized by the Patient Protection and Accountable Care Act of 2010, authorizes the Centers for Medicare & Medicaid Services (CMS) to base a portion of hospital reimbursement payments on how well hospitals perform in 25 core measures.  The goal of the VBP program is to incentivize hospitals to improve care by starting to base reimbursement on quality of care delivered. This program focused on how patients rate their hospital experience, and how well hospitals follow certain standards of care. Some of the VBP core measures ask the following:

• Were blood cultures performed in emergency department prior to initial antibiotic?
• Were prophylactic antibiotics discontinued within 24 hrs after surgery end?
• How often was pain well controlled? Continue reading

Selection in Health Insurance Exchanges – Risk or Risk-Adjustment?

The initial focus of media and industry scrutiny during the launch of health insurance exchanges was primarily the potential for adverse enrollee selection of insurance products. Healthier enrollees would opt for less comprehensive packages (or avoid enrollment), while the sicker would obtain more comprehensive coverage. The net result of this situation is the adverse selection-induced, so-called “death spiral.” In fact, the exchanges appear to have successfully captured significant numbers of younger enrollees, with the majority of enrollees opting for the benchmark silver levels. High-cost individuals within the community rated pool are accounted for by the 3Rs – reinsurance, risk-corridors and risk-adjustment, with reinsurance and risk-corridors being phased out as the initial shock of transitioning to the new insurance structure is absorbed. Continue reading

Taking a Closer Look at the July ICD-10 Coding Challenge

Blog by Sue Belley

CONTEST QUESTION:

A man from a small village in Guinea, West Africa, presented to his village health clinic with a severe headache, vomiting, diarrhea and severe pains in his back. He was initially thought to have malaria, but upon transfer to a special unit at a hospital in Conakry he was diagnosed with Ebola. The patient went on to develop disseminated intravascular coagulopathy, SIRS and shock. The patient was treated with intravenous fluid and electrolytes, vitamin K, oxygen and blood pressure support. He eventually succumbed. Assign codes for this inpatient encounter and sequence appropriately. Continue reading

Medical Necessity Documentation – the Critical Component for CAC

Whether or not you can quote chapter and verse of the Medicare statute that first detailed medical necessity, most of us in healthcare are familiar with its premise1. But from this basic tenant we begin to diverge widely in our understanding of the concept. This is especially true for Medicare inpatient services since CMS does not have specific standards the industry can follow. This issue dates back to the late 1980s when then HCFA admitted, “Current regulations are general and we have not defined the terms ‘reasonable’ and ‘necessary’ nor have we described in regulations a process for how these terms must be applied…”2 Continue reading

CDI and Document Creation: Aligning Goals and Processes

Last week I attended my first CDI Summit. As a specialist in the document creation process, I knew that I was going into the conference with a different perspective on healthcare documentation than most attendees, but I was hoping to see how the goals and processes of clinical documentation improvement (CDI) align with the goals and processes of documentation capture and quality assurance.

I was happy that all of the sessions I attended related in some way to how the documentation is being captured in health care, either through traditional dictation and transcription, speech recognition, templates, or direct data entry. On several occasions I heard the CDI mantra, “If it isn’t documented, it didn’t happen,” because the focus of CDI is on attaining accurate and timely documentation that reflects the scope of services provided to the patient. Continue reading

Will the “Quantified Self” Change Health Care?

Yes. To achieve real success in population health we need health care consumers to actively engage in the behaviors necessary to secure their health. “Patient” engagement is the holy grail of health care. However, despite decades of research into health behavior and ways to change it, we don’t seem to be any closer. I think that is about to change.

Disruptive technologies are proliferating in response to the new cultural phenomena of the “quantified self.” This movement believes each of us is a rational creature responsive to data and if we can only get enough indisputable facts about our daily life, then we can manage/change our behavior. Therefore, everything in our lives must be tracked.  This assumption is debatable — some people do not need a scale to know if they are gaining weight, a look in the mirror will do. However, for others, including myself, we seem to automatically airbrush that image in the mirror, so a little rude data every now and then may be necessary.

Continue reading

“Documentation is the beginning….not the end”

I wish I could claim this quote as my own! I attended the AHIMA CDI Summit in Washington, D.C. this week and our keynote speaker was Laura Zubulake. My two takeaways from her presentation were the quote above and the affirmation that we should always do the right thing…not the easy thing.

One of the more interesting presentations of the week was from a cardiologist who provided insights into the CDI and HIM query process from his perspective. He had an excellent grasp of what was needed for accurate coding–until that one moment. I am sure many of us have been there: listening to a presentation, engaged and learning until we hear something that makes us cringe. He described the following scenario: Continue reading