Improving Revenue Cycle Through Clinical Documentation Excellence
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1 Improving Revenue Cycle Through Clinical Documentation Excellence John Showalter, MD, MSIS Leigh Williams, MHIIM, RHIA, CPC, CPHIMS Today s Agenda Clinical Documentation Excellence (CDE) Program Program Initiation and Pilot CDE Program Metrics and Outcomes Strategic Direction Discussion 1
2 The University of Mississippi Medical Center Academic medical center 722 bed teaching hospital 28,000 inpatient admissions per year 250,000 ED and outpatient visits per year Acute and specialty care University Adult Hospital Batson Children s Hospital Wiser Hospital for Women & Infants Conerly Hospital for Critical Care Critical Access Hospital in the Delta Community Hospital 600 billing practitioners 125 specialties 100+ clinics 175 telemedicine locations 5 health sciences schools Clinical Documentation Excellence CLINICAL DOCUMENTATION EXCELLENCE PROGRAM 2
3 Program Principles Improve quality of care outcomes Improve revenue cycle metrics Use existing physician workflows Documentation will be: complete, accurate, timely Program Scope DRG and CPT based reimbursement ICD-10 Meaningful Use and overall EHR adoption Hospital Value-Based Purchasing (VBP) Program Hospital Readmissions Reduction Program Hospital Acquired Conditions (HAC) Reduction Program Department-specific pain points Sustainable into the future 3
4 Program Strategy Data-Driven No Data Actionable Knowledge Engagement None Engaged Documentation Maturity Model Data-Driven No Data Actionable Knowledge Engagement None Engaged Program Components Stage Data-Driven No data sharing Historical Descriptive Predictive Complete Limited queries Queries Education and queries Collaborative Accurate No education or templates Some structured templates Templates and work flows Optimized work flows Timely Poor Delinquency Rate 30-40% Delinquency Rate 10-30% Delinquency Rate < 10% Delinquency Rate 4
5 Working with Physicians Focus on education and support not queries Integrated into their regular work flows During care when possible In the EHR (not ) Cues integrated in the templates Physicians learn by doing See one Do one Teach one Program Accomplishments Metric Start Current Change Delinquency Rate >40% 15% 25% Cash Holding 5 days of AR 2 days of AR 3 days of AR Query Responses ~60% 85% in 48 hours 15% and faster Case Mix Index - Neurosurgery Orthopedics Unspecified Codes - Neurosurgery 13.82% 12.72% 1.1% - Orthopedics 12.35% 6.22% 6.13% - Family Medicine 21.4% 16.96% 4.5% 5
6 Clinical Documentation Excellence PROGRAM INITIATION Chart Deficiencies: Count 6
7 Chart Deficiencies: Cash Dealing with Attribution 7
8 Clinical Documentation Excellence PROGRAM PILOT: SURGICAL SERVICES Program Pilot: Surgical Services Neurosurgery Team lead: department chair Team members: Residency program director CDI nurse Hospital & pro fee coders CDE program manager CDE program leadership Initiated November 2013 Meets monthly Actively supports rounding with physicians and educational sessions Orthopedics Team lead: department chair Team members: Residency program director CDI nurse Hospital & pro fee coders CDE program manager CDE program leadership Initiated October 2013 Meets monthly Actively supports rounding with physicians, educational sessions, grand rounds monthly education, intern program on business basics 8
9 Program Description: Neurosurgery Focus on inpatient documentation Deficiencies and delinquency rate Collaborative education and discussion Structured templates and revised queries Metrics: Department cash holding (deficiencies) Query responses: timely, complete MS-DRG Case Mix Index Unspecified diagnosis code usage (ICD-9) Neurosurgery Cash Holding That s one chart (and only one chart) 9
10 Neurosurgery Query Responses Neurosurgery CMI Factor Difference CMI
11 Neurosurgery Unspecified Code Usage 16.00% 15.27% 15.52% 15.00% 14.00% 13.82% 14.33% 14.26% 14.55% 14.38% 14.08% 14.29% 13.70% 13.00% 12.97% 12.93% 12.72% 12.00% 12.52% 11.00% 10.00% % Unspecified Program Description: Orthopedics Both inpatient and ambulatory documentation Deficiencies and delinquency rate Collaborative education and discussion Structured templates and revised queries Metrics: Department cash holding (deficiencies) Query responses: timely, complete MS-DRG Case Mix Index Unspecified diagnosis code usage (ICD-9) Physician business savvy 11
12 Orthopedics Cash Holding Orthopedics Query Responses 12
13 Orthopedics CMI Factor Difference CMI Jan-13 Apr-13 Jun-13 Sep-13 Dec-13 Mar-14 Jun-14 Sep-14 Dec-14 Mar-15 Jun-15 Orthopedics Unspecified Code Usage 14.00% 13.23% 13.00% 12.35% 12.00% 11.00% 12.18% 13.07% 12.01% 11.80% 11.30% 11.44% 11.83% 12.03% 11.35% 10.00% 9.00% 8.00% 7.16% 7.00% 6.00% 7.14% 6.22% % Unspecified 13
14 Orthopedics Business Savvy 100% of residents completed a Physician Business Basics course will repeat annually Monthly Grand Rounds continue on focus areas Billing for pre- and post-op visits E&M coding Leveraging the ICD-10 diagnosis calculator Maintaining a problem list Responding effectively to queries Drafting complete discharge summaries Readmissions reduction program basics Clinical Documentation Excellence PROGRAM EXPANSION: AMBULATORY 14
15 Program Description: Family Medicine Patient care focused: Primary care physician A patient s ambulatory and inpatient documentation Metrics: Open encounters Department cash holding (discharge summaries) Query responses: timely, complete MS-DRG Case Mix Index Unspecified diagnosis code usage (ICD-9) Family Medicine Open Encounters 15
16 Family Medicine Cash Holding That s one chart (and only one chart) Family Medicine Query Responses 16
17 Family Med Unspecified Code Usage 22.00% 21.40% 21.26% 21.38% 21.00% 20.39% 20.43% 20.00% 20.44% 20.22% 19.72% 19.69% 19.27% 19.00% 19.28% 19.43% 18.00% 17.55% 17.00% 16.96% 16.00% % Unspecified Targeted Unspecified Diagnosis Codes Diagnosis Congestive Heart Failure Unspecified Asthma Unspecified Otitis Media Count in September Total Count in May
18 Clinical Documentation Excellence STRATEGIC DIRECTION New Areas of Focus Otolaryngology Surgery Targeting Medicine by subspecialty Pediatric specialties Learning from the ICD-10 transition Audiology Vascular Pulmonology Hospitalists Medical Necessity Plastics Oncology Cardiology Denials Ambulatory Surgery Transplant Trauma GI Allergy GI DRG shifts 18
19 New Ways to Communicate Goals Base DRG Rate Major DRG Capture Rate Goal is under Goal is over Feb-15 Mar-15 Apr Feb-15 Mar-15 Apr-15 New Initiatives Clinical intelligence Computer assisted physician documentation Real-time feedback through EHR dashboards Computer assisted coding Concurrent coding ICD-10 diagnosis and problem list support tools Structured template development Optimized physician work flows Physician coding help desk 19
20 John Showalter, MD, MSIS University of Mississippi Medical Leigh Williams, MHIIM, RHIA, CPC, CPHIMS University of Virginia Health 20
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