Documentation Improvement | Compliance Audits | ICD-10 Education & Coding

PEPPER Reports Released
The Fourth Release of the PEPPER Data, the short term Acute Care Program for Evaluating Payment Patterns Electronic Report, has just been released. Quarterly PEPPER Reports are distributed by TMF Health Quality Institute under contract with the CMS.  A brief refresher on PEPPER data.
PEPPER is an electronic data report that contains a single hospital’s claims data statistics for Medicare-severity diagnosis related groups (MS-DRGs) and discharges at high risk for payment errors due to billing, coding and/or admission necessity issues. Each PEPPER contains statistics for the most recent twelve federal fiscal quarters for each area at risk for payment errors (referred to in the report as “target areas”). Data in PEPPER are presented in tabular form, as well as in graphs that depict the hospital’s target area percentages over time. PEPPER also includes reports on the hospital’s top MS-DRGs for one-day stays and top medical MS-DRGs for one-day stays. In addition, the report contains Jurisdiction Top MS-DRGs for One Day Discharge Reports as well as Jurisdiction Top Medical MS-DRGs for One Day Stay Discharge Reports.
Basically, a hospital is compared to other short -term acute care hospitals in three comparison groups: State, Medicare Administrative Contractor/Fiscal Intermediary jurisdiction and the nation. These comparisons enable a hospital to determine if it is an outlier in the sense the hospital can identify if it significantly different from other short-term acute care hospitals. Of note is that PEPPER does not identify the presence of payment errors, but it can be used as a guide for auditing and monitoring efforts. A hospital can use PEPPER to compare its claims data over time to identify areas of potential concern:

The Short Term Acute Care Hospital nine target areas are as follows:

What Does PEPPER have to do with CDIS?
Notice the reference to the PEPPER data as a guide for auditing and monitoring efforts. When we think of auditing and monitoring in the context of coding and billing, one is inclined to make an association with a yearly or twice yearly outside coding audit to assess coding and billing accuracy. However, the reality is PEPPER data can certainly be a useful tool for clinical documentation improvement specialists in assessing the effectiveness and outcome of our efforts to affect positive behavioral change in physician practice patterns of clinical documentation over time. Referring to the first six target areas as appearing above, one can identify particular MS-DRGs that can be tracked and trended over time to see how the hospital is faring within these MS-DRGs from a hospital specific standpoint, comparing outcomes over time within the hospital as well as in comparison to hospitals in the state and MAC/FI jurisdiction.
This comparison from a quarterly “snapshot” perspective as well as “trending” perspective can be utilized to identify potential areas that require further investigation from a clinical documentation and clinical support/confirmation standpoint. Case in point is the diagnosis of sepsis and Urinary Tract Infections and the associated MS-DRGs:

I think we can attest to the occasional instance where we provide education to physicians on the clinical merits of documenting “Urosepsis” vs. “Sepsis with UTI” in an attempt to avoid classification and characterization of patients with clinical sepsis into the less acute simple urinary tract infection condition, a clinical entity that can possibly be managed on an outpatient basis. Based upon our best efforts to qualify sepsis from a simple UTI, there is always the distinct possibility a few physicians will take our education to heart and begin documenting sepsis on patients where there is equivocal clinical evidence in the record in support of the diagnosis. By reviewing the PEPPER data over time, we can maintain vigilance in comparison within the hospital in addition to the state, jurisdiction and nation. If the hospital’s billing patterns within a particular MS-DRG or cluster of MS-DRGs changes dramatically over time in comparison to other facilities, there may be cause for concern, raising the need for retrospective review and efforts to provide “reeducation of physicians on a particular concept of clinical documentation. Of course, we should be motivated and engaged in prospective monitoring of our efforts to affect change in clinical documentation as part of a strategy to maintain compliance with all applicable coding guideline, policies, and regulations as well as clinical conventions of documentation in support of clinical accuracy reporting.

The Next Step

I encourage clinical documentation specialist s to read the Short term Acute Care PEPPER User’s Manual which can be found here   http://www.pepperresources.org/LinkClick.aspx?fileticket=V_aMDKRO2LA%3d&tabid=59 and familiarize or refamiliarize oneself with the use and intent of the quarterly data. Capitalize upon the opportunity to utilize and incorporate the results of the data in our continued business of educating physicians on appropriate clinical documentation techniques and strategies to properly capture the true severity of the patient in conjunction with and support of the physician’s clinical judgment, acumen, and medical decision making in managing the patient’s clinical condition in a value based, cost effective, quality oriented manner. We may identify the need to update and reformat our business model and plan of clinical documentation improvement for physicians and provisions of clinical education to coding staff. If you are not yet involved in any PEPPER committees that review and analyze the quarterly data, this would be a great time to learn more about PEPPER and become an active participant in the committee. I encourage you to also read the PEEPER testimonials on different potential uses of PEEPER data that other hospitals have brought forth and experienced benefit from by clicking on the following link. http://www.pepperresources.org/Testimonials.aspx

Maintain Vigilance in All We Do