Q&A: How can CDI teams get a better handle on our organization’s PEPPER analysis?
Q: Our care coordination team has typically handled our Program for Evaluating Payment Patterns Electronic Report (PEPPER) analysis, but the department head doesn’t feel comfortable in reporting and discussing outliers other than readmissions. Can you offer any assistance into what CDI programs should be looking at from PEPPER and how to best leverage that information?
A: The PEPPER is distributed by TMF Health Quality Institute under contract with CMS on a quarterly basis—through a QualityNet secure file exchange typically in March, June, August, and December. It summarizes facility-specific data statistics for Medicare services (MS-DRGs) that may be at risk for improper payments due to coding, documentation, and/or medical necessity issues, and compares that data to other facilities within the region, as well as to facilities nationwide. The reports basically gives a detailed peek at where your facility may be vulnerable and CMS itself encourages facilities to use the data to support internal auditing and monitoring.
The first step in PEPPER review, is to figure out who has access to QualityNet. Typically, the PEPPER recipient works in compliance, HIM, utilization review, or sometimes case management. The CDI team manager or lead can work with that person or department to share information. It’s also possible to give a CDI team member the “PEPPER recipient” and “file exchange and search” roles to ensure CDI always has immediate access to the PEPPER data. (For information, visit the PEPPER Resources website.)
If no one in the facility currently receives the PEPPER, contact PEPPERresources.org to set up an account but be sure to communicate with those vested stakeholders.
PEPPER results are color coded based on the percentile the facility falls into for each of the focus areas—typically high-volume or high-dollar MS-DRGs. Black means average compared to other facilities in the region, green means the facility is a low outlier in that area (at or below the 20th percentile when compared to other facilities), and red means the facility is a high outlier in that area (at or above the 80th percentile). Though it’s a good idea to review all the data points in the PEPPER, the areas in green and red should be a particular focus for CDI.
If the organization has too many red items, it could be at risk for receiving overpayments. Too many green items and the organization could be missing out on capturing certain diagnoses. A missing data point may mean that the organization simply did not have enough discharges in that area during that timeframe to track.
Armed with that data, CDI program managers can look at record review efforts and prioritize particular MS-DRGs for additional reviews, query audits, or education for providers, CDI, or coding. Of course, an audit may reveal that there are no coding or documentation opportunities but even that information is good for the CDI department to know.
At DukeHealth in Durham, North Carolina, PEPPER data gets discussed at their quarterly compliance meetings with CDI and coding in attendance, explains Debbie Squatriglia, MS, MBA, CDIP, CCDS, CDI department director there. Care coordination reports on readmission, compliance on evaluation and management (E/M) levels, and CDI and coding report on any MS-DRG outliers. She currently has a dedicated CDI informatist who pulls the data and analyzes it as part of their role.
SCL Health in Broomfield, Colorado, follows a similar pattern with CDI performing an audit on any MS-DRG outliers and reporting back on documentation related opportunities, coding performing their own audits for coding accuracy and other departments focusing on concerns related to medical necessity, readmissions, and E/M, says Carrie Willmer, RN, CCDS, CDIP, CDI department director there.
Whether the PEPPER spurs chart reviews or supports them and validates CDI efforts, using the data will help minimize denial and audit risks, too. Since the PEPPER is based on DRGs, review of the reports means a chance to collaborate with coding in the fight against denials.
Editor’s Note: For additional information about PEPPER analysis read ‘Pass the PEPPER’ from the CDI Journal. Additional resources include: