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CVSIt’s Not Just a Pharmacy Anymore

By: Jeanne Day, RHIA CHAMDirector of Health Information Management & Patient Access

Welcome to CVS – It’s Not Just a Pharmacy Anymore

Presented By:Jeanne Day, RHIA CHAM

Director of Health Information Management & Patient Access

What is Maryland’s state bird?

MEBTLARIO LEOOIR

Maryland Trivia

Baltimore Oriole

Maryland Trivia

Thoroughbred racing comes to Maryland on the third Saturday in May each year for the second and shortest leg in The triple

Crown. What is the name of this race?

HET ERSAKNPES SKTEAS

Maryland Trivia

The Preakness Stakes

Maryland Trivia

What famous poet is buried in Baltimore?

DERAG LNLAA EOP

Maryland Trivia

Edgar Allan Poe

Maryland Trivia

Name the patriotic song that was inspired by Francis Scott Key’s poem “Defense of Fort McHenry”?

TEH RTAS-DANPGSELE NEANRB

Maryland Trivia

TheStar-Spangled

Banner

Maryland Trivia

Greater Baltimore Medical Center

Greater Baltimore Medical Center is a 239-bed medical center (acute and sub-acute care).

Since its founding in Towson in 1965, GBMC's accomplishments have validated the vision of its founders to combine the best of community and university-level medicine.

GBMC PHYSICIANSNearly 1,300 physicians serve on GBMC's medical staff, making it among the largest of any community hospital in the mid-Atlantic region.

GBMC and its physicians have long been recognized for outstanding quality and personalized service within the community. Over the past decade, U.S. News & World Report has repeatedly cited the medical center as one of "America's Best Hospitals" in several areas of service. Additionally, Baltimore Magazine's annual "Top Doctors" edition consistently recognizes more members of GBMC's medical staff than that of any other hospital in the state.

GBMC NURSES

GBMC's nursing staff consists of 1,100 Medical Center nurses and 126 Hospice nurses, with an average length of employment of 10 years.

GBMC STAFF AND VOLUNTEERS

GBMC employs approximately 3,500 people in clinical and non-clinical areas, making the organization one of the largest private sector employers in Baltimore County. An additional 800 community members volunteer their time at the Medical Center and Gilchrist Hospice Care.

GREATER BALTIMORE HEALTH PARTNERS

Greater Baltimore Health Partners is a group of more than 40 physician practices owned by GBMC, operating on the hospital's main Towson campus as well as in satellite locations across the region. GBMA practices experienced more than 250,000 patient visits last year, with almost 200 physicians available to care for community members.

GILCHRIST HOSPICE CARE

Gilchrist Hospice Care, a Medicare/Medicaid certified hospice program, is the largest hospice organization in the state of Maryland. Since 1994, care and services have been provided to over 30,000 terminally ill individuals.

Services include medical, nursing, social work, hospice aide, spiritual care and bereavement counseling/support and volunteer assistance.

GILCHRIST HOSPICE CARE

Hospice services are most often provided in the patient’s home or place of residence. When more intensive care is required, patients may be admitted to the organization’s 34-bed inpatient hospice facility, Gilchrist Center Towson or its 10-bed inpatient facility in Columbia, Gilchrist Center Howard County.

In 2010, Gilchrist expanded its program to care for infants, children and teens through Gilchrist Kids.

GBMC FOUNDATIONFounded in 1987, the GBMC Foundation was established to centralize and coordinate fundraising efforts to benefit GBMC. The Foundation executes fundraising events, annual appeals and capital campaigns and seeks gifts from grateful patients and other friends of GBMC, as well as grants from corporations and private foundations.

Gifts to the Foundation support new facilities, equipment for GBMC physicians and staff, specialty programs and technologies. Charitable contributions total more than $100 million in the last two decades.

FY18- 54,662 ER Visits

- 16,802 Outpatient Surgical Procedures

- 21,271 Inpatient Discharges

- 4,974 Observation Stays

GBMC is the only healthcare system in Maryland to achieve HIMSS Stage 7 on the HIMSS Analytics Electronic Medical Record Adoption Model (EMRAM) for both Inpatient and Ambulatory Care.

Maryland Payment System

Maryland operates the nation’s only all-payer hospital rate regulation system. This is in part due to a 40 year-old Medicare waiver that exempts Maryland from the inpatient and outpatient prospective payment system allowing Maryland to set rates for these services.

Maryland uses the APR-DRG system as opposed to the MS-DRG system used by the rest of the nation.

These differences mean that Maryland’s reporting is based on Case Mix Index data instead of dollar amounts. Maryland doesn’t report CCs and MCCs, instead we report SOIs (1-4) and ROMs (1-4).

Applications Software

• Epic• 3M Encoder• 3M 360 Encompass – Go-Live

August 2018• 3M 360E Audit Expert – Go-Live

Q1 CY19

The Way We Were – CDI

• “Traditional” CDI program• 2 Exempt FTEs• RN Required• Reported to Compliance• Concurrent review and querying on inpatient accounts – starting on second day with

follow up reviews every two days until discharge • No productivity or quality standards• Reviewed 17% of inpatient accounts

The Way We Were – Inpatient Coding

• “Traditional” Coding Program• 6 Non-Exempt FTEs• Reported to HIM• Retrospective coding and querying• Productivity Standards – 3 charts/hour

Where We Are

• Coder and CDI Specialist job functions have been combined into a new role – Clinical Validation Specialist (CVS).

• Clinical Validation – Implemented in February 2018

• Clinical Validation performed to ensure documentation in the medical record supports each diagnosis documented as well as to the diagnoses are based on supporting findings.

• The Clinical Validation Specialists are performing concurrent coding and clinical validation on Inpatient accounts. Approximately 74% of inpatient accounts (LOS > 2 days) are being coded and clinically validated concurrently.

Coding and Clinical Validation Vision Statement

GBMC’s Coding and Clinical Validation Department is responsible for providing precise coding and clinical validation of health information to ensure reliable data reporting and accurate reimbursement.

Coding and Clinical Validation Organizational Chart

Jeanne Day, RHIA, CHAMDirector

Health Information Management and Patient Access

Clinical ValidationInformatics Specialist

1.0 FTE

Clinical Validation and Coding Auditor

1.0 FTE

Coders3.0 FTE

Clinical Validation Specialists 8.0 FTE

Cathy Testerman, CCS, CCDSManager of Coding and

Clinical Validation1.0 FTE

Clinical Validation Specialist (CVS) Requirements

• The CVS is responsible for improving the overall quality and completeness of clinical documentation; facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. Utilizes both clinical and coding knowledge to obtain appropriate documentation.

• CCS or CIC required; CCDS or CDIP required within a year of hire.• Minimum three years experience in inpatient coding or other clinical disciplines with

either coding or CDI experience or an equivalent combination of these disciplines.• Demonstrated knowledge of medical terminology and anatomy and

physiology. Knowledge of ICD-10-CM and PCS coding guidelines and DRG assignment.

CVS Benefits• Non-Exempt• Work Remotely• Workstation

o Laptopo Dual Monitorso Docking Stationo Cordless Mouse and Keyboard

• $50/month Reimbursement for Internet Access• AHIMA and/or ACDIS Membership • Opportunities to Obtain CEUs

**Inpatient Coders taking CVS positions received a 10% pay increase

Training Provided for CVSs

CVSs received training on severity methodology, present on admission criteria, MHACs and sending meaningful queries.

Training included twenty-two modules that covered individual major diagnostic categories such as urinary, respiratory, cardiovascular, etc..

CVS Workflow

Discharged Inpatient Accounts WorkqueueCVSs complete discharged accounts they reviewed concurrently.

Accounts are held if they require additional documentation (Discharge Summary, Operative Note, Unanswered Queries, etc.).

Subsequent Concurrent Review WorkqueueCVSs rereview inpatient accounts every two days after initial review until the patient is discharged.The CVSs update the account status to “In Progress” when working on an account and to “Concurrent Review Started” when they complete their review. These statuses allow us to track productivity and is the logic Epic uses to route the accounts into this workqueue.

CVS Workflow

Inpatient In-House Accounts Workqueue

All inpatient accounts are routed to this workqueue. The CVSs review the oldest accounts first performing an initial documentation review.

Preliminary codes are entered, initial abstracting is completed, queries are sent, and document deficiencies are entered for to request missing documentation. CVSs enter detailed notes in the comments including the date and time of the last document they reviewed. This allows them to easily pick up where they left off at the next review and allows someone else to complete their accounts should they be unavailable to complete the account at the time the patient is discharged.

Query Process

• Queries are created in Epic. • Completed queries are maintained as part of the medical record.• Deficiencies are assigned to all queries. Providers must complete query

deficiencies to avoid suspension of admission and posting privileges. • Accounts are not finalized until all queries are answered.

Query Volume60 Query Templates

Top 5 Queries Sent• Communication – 14%• Abnormal Lab Value - 10%• Asthma - 9%• Congestive Heart Failure - 8%• Sepsis - 7%

Query Volume by Specialty• Internal Medicine - 62%• General Surgery – 9%• Pulmonary – 7%• Obstetrics – 5%• Critical Care – 4%

Query Volume

212234

715754

Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18

Queries35

Query Rate

30.89%

37.37%

31.49%26.69%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Feb Mar Apr May June36

Average Query Response Time

113 112107

Query CriteriaGBMC’s Clinical Documentation Inquiry policy defines query criteria:

Queries where the physician diagnosed out of defined criteria will be provided for physician champion review and follow up.

Result/Diagnosis Criteria Abnormal Lab Values Abnormal Lab Value as indicated by GBMC or

Reference Laboratory and patient treatment based on lab value.

Acute Renal Failure Maryland Hospital Association (MHA) Aspiration Pneumonia Maryland Hospital Association (MHA) Chronic Renal Failure National Kidney Foundation Glasgow Coma Score = 3 - 8 Glasgow Coma Scale Malnutrition American Society for Parenteral & Enteral Nutrition

(ASPEN) Obstetrical Hemorrhage Maryland Hospital Association (MHA) Pneumonia Maryland Hospital Association (MHA) Sepsis GBMC Defined

Communication Queries

Communication Queries are reviewed monthly to evaluate the need for additional query templates.

Queries Developed as a Result of Communication Query Reviews:

• Hypertensive Crisis• Encephalopathy• Urinary Retention• Palliative/Comfort Care• Kidney Cyst – Acquired vs Congenital

Productivity Standards

1.5 charts per hour (includes initial and re-reviews)

Average CVS Productivity – 1.74 charts per hour

Quality Standards• Minimum Requirement of 95% accuracy • Quality determined by monthly internal audits on 10 accounts/CVS

and annual external audit. • Audits include:

o Missing codes that may change DRG, SOI and/or ROM o Incorrect codeso Appropriateness of queries sent o Missed query opportunities

• CVS Quality – 98.82%

Documentation Audits

• Review Mortality cases with ROM < 4ROM increased on 38% of accounts reviewed

(Data for January-June 2018)

• Review of Sepsis cases with ROM < 4ROM increased on 12% of accounts reviewed

(Data for February-May 2018)

• Changes shared with CVS who reviewed/coded the account.

Provider Education

• Provider education provided for Maryland Hospital Association (MHA) criteria - Acute Kidney Injury, Pneumonia and Respiratory Failure.o Advanced Practitionerso Facultyo Residentso Hospitalistso Intensivistso Infectious Disease MDso Surgeonso Kaiser MDs

• Developed Documentation Tips Pocket Guide for Provider Reference• Added to Hospital Infoweb & Epic Learning Home Dashboards

Maryland Hospital Acquired Conditions

The Maryland Hospital Acquired Condition (MHAC) program was implemented in FY11 to link the hospital payment with hospital performance using 3M’s potentially preventable complication (PPC) classification system. These are similar to the HACs.

CY2017 MHACs - 231CY2018 MHACs – 131 (through June)

Case Mix Index (CMI)

0.815940.828052

0.817108

0.790560.802365

0.833308

0.898440.903853

0.934116

0.8505240.850136

0.816390.8200110.8113570.814119

0.802215

0.859641

0.8191410.828354

0.84418

0.870094

0.808190.822709

0.85614

CMI Comparison

Severity of Illness (SOI)Total Finalized Accounts 20,989

36%34%

36%35%

34% 34%35%

33%35% 35%

40%41% 41%

40%38% 38%

37% 37%36%

38%39%

21% 21%22%

21% 21%

24%23%

24%26%

24% 24%23%

2%3% 3%

2%4% 4%

5%4% 4%

SOI 1 SOI 2 SOI 3 SOI 4

Risk of Mortality (ROM)Total Finalized Accounts – 20,989

65% 64%

64% 63%60% 60% 60%

61% 61% 61%

19% 20%22%

20% 19%22%

20% 20% 20%18%

20%18%

14% 14% 15% 14% 15% 14%16%

18% 18%15% 15% 15%

2% 2% 3% 2% 3% 4% 4%2%

5% 6%4%

ROM 1 ROM 2 ROM 3 ROM 4

Documentation Improvements

• BMI being converted to a diagnosis on the Discharge/Transfer Summary.

BMI less than 18.5 – UnderweightBMI is 18.5 to <25 - NormalBMI is 25.0 to <30 - OverweightBMI is 30.0 – 34.9 - ObesityBMI of 35 – 39.9 = Morbid ObesityBMI >40 – Severe Morbid Obesity

• Dietary documenting malnutrition diagnoses which are pulling into the Discharge/Transfer Summary.• Attending Physician has the opportunity to edit and/or sign off diagnosis listed in the

Discharge/Transfer Summary.

Where We’re Going• Pull wound and/or wound stage documentation into the Discharge/Transfer Summary. The inclusion of this

information in the Discharge/Transfer Summary should reduce the number of queries being sent on wounds as well as having a potential impact on the SOI, ROM, etc..

• Monthly documentation audits on the 5 providers who received the most queries. Follow up with individualized feedback to improve documentation.

• Define clinical criteria definition for CHF & UTI.• Participation on Care Variation Teams (Sepsis, Colorectal, Ortho,

COPD, CHF)• Participation on MHAC Review Team• 3M 360 – Go-Live Scheduled for August 8, 2018

o Computer-Assisted Coding

o Clinical Documentation Improvement – Improved quality and productivity of CVSs

o Quality – Real-time identification of potential quality issues for review

Questions?

Contact Information

Jeanne Day, RHIA CHAMDirector of HIM & Patient Accessjday@gbmc.org443-849-3554

Cathy Testerman, CCS CCDSManager of Coding & Clinical Validationctesterman@gbmc.org443-849-2023

Sydney Neblett, CCSClinical Validation and Coding Informatics Specialist443-849-3728sneblett@gbmc.org

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