Guest post: Painting the picture of patient care for population health directives

by Adriane Martin, DO, FACOS, CCDS

To be successful CDI programs need to expand across the care continuum into the ambulatory and the post-acute care setting to capture all diseases and conditions that paint the picture of patient care.

An example of that expanded focus might include the diagnosis of dementia. ICD-10-CM code F03.90 (unspecified dementia) has no impact in terms of the MS-DRG but can increase a patient’s risk of poor outcomes. This increased risk is reflected in the fact that the diagnosis of dementia is a risk adjustment factor (RAF) for many quality measures such as CMS’ 30-day measures for readmission and mortality, and for cohorts within the PSI-90 composite.

Consider a scenario in which a patient is admitted and treated for an acute condition unrelated to dementia. The patient is continued on his home medications for dementia, but his dementia is never documented by the physician. That’s a CDI opportunity.

ICD-10-CM code J44.9 (unspecified chronic obstructive pulmonary disease [COPD]) is used to report another diagnosis that is not an area of interest in traditional inpatient CDI programs unless there is an acute exacerbation. Often, a patient living with COPD is admitted for an unrelated acute condition and continues his or her home regimen for COPD. Failure to report ICD-10-CM code J44.9 has a negative effect on expected outcomes for CMS’s 30-day readmission and mortality measures, as well as the PSI-90 composite.

Unspecified COPD falls under hierarchical condition category (HCC) 111. HCCs are used in the calculation of the RAF score. RAF scores are in turn used in the determination of quality measures as well as payments by plans such as Medicare Advantage and accountable care organizations.

Higher RAF scores are associated with higher reimbursement as they denote patients with more significant comorbidities. For each condition that a patient presents with that falls into an HCC, the RAF score is increased. Several of the diseases or conditions that are part of an HCC are chronic in nature and not the typical focus of a traditional inpatient CDI program. However, failure to incorporate such diagnoses may negatively affect a hospital’s bottom line.

For example, chronic kidney disease has long been a focus of CDI due to its MS-DRGs, risk of mortality, and severity of illness. However, it will also function as an RAF in CMS’ 30-day readmission/mortality measures and PSI-90 composite. In some instances, for this diagnosis to function as a RAF for a quality measure, the diagnosis must be captured in the 12 months preceding the inpatient hospital admission. Depending on the stage of the chronic kidney disease, it may also fall into an HCC.

Conclusion

In population health, documentation across the care continuum matters, as both Medicare Part A and Part B claims are considered when expected outcomes and costs are calculated. Performance measured against expected outcomes and costs of care can be used to jumpstart quality initiatives and influence public perceptions in the form of a CMS star rating.

CDI professionals are on the front line in assuring that Part A and Part B claims data accurately reflect the acute and chronic conditions of the patient. To be successful, now and in the future, the focus of CDI programs must expand across the continuum of care to include the ambulatory space and the capture of diagnoses that have not traditionally been on the priority list.

Editor’s note: This article originally appeared in JustCoding. To read the first part of this article, click here. Dr. Martin is vice president of Enjoin in Eads, Tennessee. She has provided clinical insight and education as part of the pre-bill review process since 2014. She is board-certified in general surgery, assists with documentation improvement, and provides specialty-to-specialty physician education in areas related to ICD-10, with a focus on surgical procedures and ICD-10-PCS. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.