Tony Matejicka, DO, MPH, FACP Medical Director Coding and Utilization August 20, 2012

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1 Tony Matejicka, DO, MPH, FACP Medical Director Coding and Utilization August 20, 2012

2 Understand the history of CMS to appreciate our clinical disconnect from Medicare reimbursement. Recognize terms from administrators CMI, DRG s etc.. Identify how documentation affects hospital payments and future pay-for-performance metrics. Improve knowledge, attitudes, and skills surrounding documentation to be successful in the marketplace. 2

3 July 30, 1965 and July 1,1966.(Medicare). October 6, ICD-9 with adoption January (17,000 codes). The current Medicare system was started in 1983 when the Reagan administration instituted sweeping reforms in the Medicare reimbursement system to keep the program from insolvency. The emergence of the Prospective Payment System (PPS) was passed into law. The PPS changed the manner of reimbursement from paying hospitals for services rendered to a new model of payment by a predetermined set rate based on diagnosis. 3

4 The Diagnostic Related Group (DRG) system was created by John Devereaux Thompson and Robert Barclay Fetter from Yale University with support from what is now known as Centers for Medicare and Medicaid Services (CMS), to be used as a template for payments to hospitals. 4

5 5

6 6

7 Each DRG has an assigned weight. Pneumonia = (wt.) Acute MI = (wt.) Hip procedure = (wt.) CABG = (wt.) Hospitals focus on volume to improve revenue. 7

8 The Relative Reimbursement is the amount the Hospital receives for each Diagnosis Related Group based on DRG weights. (previous slide examples) 8

9 CMI= Case Mix Index or weight for each DRG (Diagnosis Related Group) divided by # of discharges. Lower weight = Lower payment. Higher weight = Higher payment. Surgical (usually) > Medical 9

10 Medicare reimbursement for hospitals involves four simple steps: 1. The Provider documents all relevant diagnoses and procedures; 2. The coder assigns a DRG as listed by the Provider; 3. Each DRG has a defined Relative Weight; 4. Relative Weight drives reimbursement and is purely volume driven. 10

11 So from this Hospital methodology we want volume! The more we see; the more the Hospital and provider receives. This created the wrvu system (work Relative Value Unit) Medicare pays physicians for services based on submission of a claim using one or more specific CPT codes. Each CPT code has a Relative Value Unit (RVU) assigned to it which, when multiplied by the conversion factor (CF) and a geographical practice cost adjustment (GPCI), creates the compensation level for a particular service. 11

12 WRVU S REIMBURSEMENT $ $ $ $ $ $ $ $196 12

13 Prior to October 1, 2007 and since 1983 Pay for procedure/diagnosis. One DRG (538)= Diagnosis-Related Group. One payment= volume. After October 1, MS-DRG s (Medicare Severity Diagnosis Related Groups) Comorbid Conditions (CC) Major Comorbid Conditions (MCC). 13

14 CMS (Centers for Medicare and Medicaid Services) lowered the relative weights for the base DRG s; thus, staying budget neutral but reducing payments. Example Acute MI: $6,840 prior to 10/2007 (wt ) $5,083 after 10/2007 (wt ) 14

15 Year after year we make less and less money, even when more resources are consumed to provide the required care. Have you ever been told you need to cut your budget? 15

16 PRIOR TO 10/2007 Revision of hip or knee replacement $17, (wt ) AFTER 10/2007 Revision of hip or knee replacement without CC/MCC $16, (wt ) Revision of hip or knee replacement with CC $20, (wt ) Revision of hip or knee replacement with MCC $31, (wt ) 16

17 PRIOR TO 10/2007 Pneumonia $5,620 (wt ) AFTER 10/2007 Pneumonia no CC/MCC. $4,400 (wt ) Pneumonia with CC. $6,200 (wt ) Pneumonia with MCC. $8,900 (wt ) 17

18 PRIOR TO 10/2007 Acute MI: $6,128 (wt ) AFTER 10/2007 Acute MI w/o CC/MCC. $5,083 (wt ) Acute MI w/ CC. $7,223 (wt ) Acute MI w/ MCC. $11,384 (wt ) 18

19 Key words now determine the quality of care, the patient s severity of illness, and provide triggers for reimbursement. I N C O N C E I VA B L E! I do not think that word means what you think it means. 19

20 Year after year we make less money, even when more resources are expended to give required care. National rankings are now determined by the patient s severity of illness, quality of care, and triggers for reimbursement. No one told the Providers!!! 20

21 21

22 Here is how those national rankings are determined: Each of the 751 MS-DRG s, while associated with a weight, is also associated with a: GMLOS (geometric length of stay) SOI (severity of illness) ROM (risk of mortality) From the SOI & ROM we can determine the Mortality Index and hospital payments and now 22

23 .pay for performance! From Section 1848 of the Healthcare bill: Being called the value based payment modifier. Moving from a volume driven model of care to quality and performance. Providers Your are not aware; we focus on wrvu s. hospital data will determine your income! 23

24 Accelerated HTN Acute/Chronic anything (cirrhosis) Acute/Chronic Systolic/Diastolic CHF Exacerbation of COPD/asthma Acute Respiratory Failure? EMS/ED/Nurses notes/radiographic studies Cerebral edema, nutrition, AKI 24

25 Be critical and precise no subjective symptoms. Identify the Principal diagnosis. (There can be ONLY ONE no vs. ). It is the condition, identified after study, which caused the patient to be admitted. Follow correct coding guidelines AND obtain documentation vital to identifying the DRG. Report all Comorbid Conditions or complications (MCC s/cc s). 25

26 Providers play the ultimate role in accurate DRG assignment! 26

27 CC: SOB HPI: 72 y.o. from SNF on BiPAP in ED diagnosed with HAP/CAP in right middle lobe. BC drawn, on three antibx, and now on 4LNC. PMedHx.: Documented A.Fib. with RVR Uncontrolled DM Previous CVA with aphasia Hypertensive urgency CHF Patient returned to SNF on day 5. 27

28 Patient had a previous CVA and likely aspirated therefore: Probable Aspiration Pneumonitis Acute Respiratory Failure 28

29 BEFORE HAP: MS DRG 195 Simple Pneumonia and Pleurisy w/o CC/MCC SOI = 1 ROM = 1 GMLOS = 3.0 days Patient returned to SNF on day 5. Payment to hospital: $4, DOCUMENTATION ACCURACY Now it s MS DRG 177 Respiratory Infections & Inflammations w/ MCC SOI = 3 ROM = 3 GMLOS = 6.7 days Patient returned to SNF on day 5. Payment to hospital: $12, Difference of $8,444.94, plus UR benefits and P4P for provider. 29

30 72 y.o. admitted to ICU from day surgery for ocular tear repair. In recovery room, failed to extubate and the next day is noted to have elevated troponins (0.52, 0.50, 0.40) and an abnormal ECG. Surgery requested a consult to assess for NSTEMI, likely demand from stress of surgery. Recommendation from consultant, evaluate and monitor with tele, ECG Q 6 hrs.x 3, increase Beta-blocker. Plan: CAD with elevated troponin, suspect demand ischemia due to her brief episode of hypoxemia postoperatively. I doubt plaque rupture. Suggest Cardiology consult. Patient was hospitalized for 3 days. Coded and billed as Non-extensive surgery, DRG

31 Patient had chest pain, ECG changes, and positive troponin therefore; Assessment/Plan: 1. POD#1: Ocular tear repair per surgery. 2. Probable NSTEMI monitor, ECG Q6 x 3, increase B-Blocker. 3. Type 2 MI-demand ischemia. 31

32 MS-DRG 989 Nonextensive O.R. MS-DRG 987 Nonextensive O.R. procedure unrelated to principal diag. procedure unrelated to principal diag. w/o CC/MCC w/mcc SOI = 2 ROM = 1 GMLOS = 2.4 days Payment to hospital: $6, (Remember, patient discharged on day 3.) SOI = 3 ROM = 2 GMLOS = 8.9 days Payment to hospital: $20, Difference of $14,446.87, plus UR benefits and P4P for provider. 32

33 Hypotension, pressors, fluid resuscitation = Shock Mental status change = Acute Delirium, Encephalopathy Troponin spill/demand Ischemia = NSTEMI Hypoxemia, Respiratory Distress = Acute Respiratory Failure CVA with left-sided weakness = Hemiplegia or Hemiparesis 33

34 There are many conditions that can be classified into Acute or Chronic conditions and these carry different relative weights. CHF (not dysfunction) Acute and/or Chronic Systolic and/or Diastolic Acute Cor pulmonale (not just Cor pulmonale) Acute Renal Failure (not insufficiency) Acute Exacerbation of COPD (not just exacerbation) Acute Respiratory Failure (not hypoxemia or insufficiency) Acute on Chronic Liver Failure (not just cirrhosis) 34

35 Symptoms are NOT diagnoses. Examples of symptoms: Chest pain Fever Weakness Hypoxemia Falls Shortness of breath Nausea/vomiting Abdominal pain Syncope 35

36 Avoid post-op anything! This will ding the surgeon by inferring (to a medical coder) the condition was a negative outcome of the operation. Avoid using R/O (rule out). This means the diagnoses have been excluded to a medical coder. Avoid using H/O (history of). This means that the condition was in the past and is not active. 36

37 Post op Pneumonia Post op Atrial Fibrillation R/O Myocardial Infarction H/O Cerebrovascular Accident 37

38 The reason the patient is admitted to the hospital after procedures and workup. In the world of coding, Possible, Probable, and Likely are acceptable. The Discharge Summary is the H & P for the Payor. 38

39 Identify all secondary diagnoses, whether POA or occurring during your care. Include all diagnosis treated during hospital stay. (CC and MCC s) Diagnose and Document Abnormal Labs, Radiographic Studies, Nursing Notes, Pathology Reports, and Nutritional Status. Use language, not arrows or numbers. 39

40 Will documenting negatively affect my National Database score? How many times do I need to document secondary Dx? If the consultant states the Dx, do I need to as well? What s in this for me? It only makes $$$ for the Hospital. What if I agree with the medical student s notes??? Do you want to see one more patient or take one minute to improve your documentation??? 40

41 Rules change rapidly with little/no notice to providers. ICD-9 going to ICD-10 October (17,000 to 140,000 codes) This will only get more difficult. When you think you ve got it You don t! 41

42 42

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