Developing an ED Facility Charge Calculator March 3, 2016 ...€¦ · Developing an ED Facility Charge Calculator March 3, 2016 4:00pm Neal Kothe, The Ohio State University Wexner

Developing an ED Facility Charge Calculator

March 3, 2016 4:00pm Neal Kothe, The Ohio State University Wexner Medical Center

Carol Gray, The Ohio State University Wexner Medical Center

Conflict of Interest Neal Kothe Carol Gray MSN, RN, CCRN, CEN SANE-A Has no real or apparent conflicts of interest to report.

Agenda • Local Problem and Intended Improvement

– Evaluation – Development

• Integration

– Integrated workflow – Testing

• Results – Sustainability – Financial considerations

Learning Objectives • Create an ED Facility Level of Service Calculator • Implement an Integrated Level of Service Calculator • Validate Facility Levels of Service

1.6 M outpatient visits

annually

1,100 attending physicians

57,000+ admissions

annually

800+ residents and

fellows

117,000+ ED visits annually

132,000+ OSUMyChart

users

3,200+ registered

nurses

18,000+ end users

Local Problem and Intended Improvement • Prior to the facility charge calculator implementation, OSUWMC’s

two Emergency Departments followed different charging methodologies. – University Hospital used specifically trained ED coders to

apply codes. – University Hospital East had all nurses apply codes on

paper. • The charging methodologies led to a number of inconsistencies

and potentially lost revenue. – Epic offered the opportunity to correct these issues. – Singular charting and charging system allowed for uniform

charging across multiple locations.

Intended Improvements • To address the inconsistencies, Epic:

– Provides automatic charging, working from documentation as it was entered in the chart.

– Provides consistent charging across patients. – Removes the need for the nurse to interpret and apply the level

of service that could negatively impact revenue. – Allows for a cumulative assigned level when multiple activities

are performed on the patient.

Alternative Solution • We were concerned about our revenue, and we had a third-party

evaluation to determine whether we were capturing revenue appropriately.

• The third party evaluation showed potential lost revenue: – They estimated an increase of roughly $15 per Emergency

Department visit. • Fees for the third party’s solution were $3.65 per patient, for

an estimated annual total $401,500. – The solution could result in increased revenue of $1,650,000

annually.

Developing the Charging Rules • Development of charging tool

– Team consisted of one IT person and 2 nurses. • Weekly development meetings for 2 months. • Several calls with current Epic customers.

– Most customers didn’t test as much as OSU. • Rules developed by nursing.

Developing the Charging Rules • These rules incorporated the normal workflow for the ED users and

each rule would help build the FCC level. While a nurse documents in the normal workflow, a level of service accumulates a score that in turn assigns the proper level of service for hospital service charges.

• Rules automatically assign level of service based on complexities documented in the patient’s chart.

Old Charging Methodologies • Poorly supported by medical record

documentation • Required recall of nursing to the events of the

patient visit • Involved interpretation and recall of charging

definitions by nursing. • Did not allow for patients receiving multiple

activities of the same level to be assigned a higher level

New Charging Methodology Rule Name Charge Rule Description # of points per action Cumulative?

ED VITALS SCORE Number of times a set(2 or more) vitals are entered up to a total of 8 times(80 points max) 10 yesED DISPO Points based on the patient ed discharge disposition of ambulatory 1 noED DISPO Points based on the patient ed discharge disposition AMA 30 noED DISPO Points based on the patient ed discharge disposition ambulance 100 noED DISPO Points based on the patient ed discharge disposition wheelchair 30 noED MEANS OF ARRIVAL Points based on the patient's arrival method of Police 30 noED MEANS OF ARRIVAL Points based on the patient's arrival method of Private Ambulance 30 noED MEANS OF ARRIVAL Points based on the patient's arrival method of Air 30 noED MEANS OF ARRIVAL Points based on the patient's arrival method of Hospital Transport 30 noED MEANS OF ARRIVAL Points based on the patient's arrival method of Other 5 noED MEANS OF ARRIVAL Points based on the patient's arrival method of Private Vehicle 1 noED MEANS OF ARRIVAL Points based on the patient's arrival method of Taxi 1 noED MEANS OF ARRIVAL Points based on the patient's arrival method of Public Transport 1 noED MEANS OF ARRIVAL Points based on the patient's arrival method of EMS 30 noED MEANS OF ARRIVAL Points based on the patient's arrival method Wheelchair 10 noED MEANS OF ARRIVAL Points based on the patient's arrival method State Vehicle 30 noED BEHAVIORAL RESTRAINTS Points based on the patient's documentation of restraint order 300 noED ASSISTIVE DEVICE Points based on the patient's documentation of assistive devices 5 noED DISCHARGE TEACHING Points bases on the patient's documentation of simple/moderate teaching 1 noED DISCHARGE TEACHING Points bases on the patient's documentation of complex teaching 30 noED CARDIAC MONITORING Points bases on the patient's documentation of 3 lead monitoring 100 noED CARDIAC MONITORING Points bases on the patient's documentation of 5 lead monitoring 100 noED ENEMA Points bases on the patient's documentation of enema type 100 noED WOUND CARE Points bases on the patient's documentation of negative pressure wound 30 noED WOUND CARE Points bases on the patient's documentation of negative pressure setting 30 noED WOUND CARE Points bases on the patient's documentation of wound packing 10 noED WOUND CARE Points bases on the patient's documentation of dressing wound 10 noED WOUND CARE Points bases on the patient's documentation wound irrigation 10 noED WOUND CARE Points bases on the patient's documentation wound interventions 10 noED PELVIC EXAM Points bases on the patient's documentation of pelvic exam chaperoned 30 noED CAST APPLICATION Points bases on the patient's documentation any cast type 10 noED EYE IRRIGATION Points bases on the patient's documentation of eye irrigation fluid 30 noED EAR IRRIGATION Points bases on the patient's documentation type of irrigant used 30 noED INCONTINENCE CARE Points bases on the patient's documentation of bladder or bowel incontinence 30 noED HYPO/HYPERTHERMIA Points bases on the patient's documentation of hypothermia or hyperthermia 3000 noED PACER Points bases on the patient's documentation of pacer placement location 3000 noED FHT Points bases on the patient's documentation of fetal movement 30 noED VISUAL ACUITY Points bases on the patient's documentation left visual acuity 10 noED VISUAL ACUITY Points bases on the patient's documentation right visual acuity 10 noED VISUAL ACUITY Points bases on the patient's documentation bilateral visual acuity 10 no

CER export

1

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Chronicles: S,,S,,N,N,Y,,,,,,,,,,,,0,,,,,,,,,20020

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Chronicles: D,,S,,R,N,Y,N,,N,,N,,,,,N,,1Not a category itemNot a category itemNot a category item

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Chronicles: S,,M,,N,N,N,N,,Y,,,,E;FCT;,,,N,,0No help text available.No help text available.Select the context type for the rule.

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Rule ID

Chronicles: #IGNORE_ROWRULE ID

Chronicles: #LAST_COLName

Chronicles: RULE NAME

Chronicles: Select cell to view item help text.Contact Date

Chronicles: CONTACT DATEContext

Chronicles: CONTEXT TYPE

100336ED VITALS SCORE01/28/200749000

100303ED DISPO01/17/200749000

100285ED MEANS OF ARRIVAL01/16/200749000

100320ED BEHAVIORAL RESTRAINTS01/23/200749000

100340ED ASSISTIVE DEVICE01/28/200749000

102499ED DISCHARGE TEACHING05/13/200949000

107796ED CARDIAC MONITORING03/25/201149000

107797ED ENEMA03/25/201149000

102501ED WOUND CARE05/13/200949000

102653ED PELVIC EXAM05/13/200949000

102639ED CAST APPLICATION05/13/200949000

102646ED EYE IRRIGATION05/13/200949000

107804ED EAR IRRIGATION03/25/201149000

107805ED INCONTINENCE CARE03/25/201149000

102651ED HYPO/HYPERTHERMIA05/13/200949000

107850ED PACER03/31/201149000

107967ED FHT04/11/201149000

102647ED VISUAL ACUITY05/13/200949000

107971ED CHEST TUBE04/11/201149000

108032ED CONTACT ISOLATION04/19/201149000

108038ED IV INSERTION04/19/201149000

108084ED LAB04/21/201149000

102661ED O2 DEVICE05/13/200949000

108089ED VENT04/21/201149000

108090ED IMMUNIZATION04/21/201149000

108092ED NGT04/21/201149000

108104ED L&D04/21/201149000

108122ED EKG04/25/201149000

108130ED NON VIOLENT RESTRAINT04/26/201149000

108131ED VIOLENT RESTRAINT04/26/201149000

108168ED POCT RAPID STREP A05/02/201149000

108171ED POCT OCCULT BLOOD STOOL05/02/201149000

108173ED POCT TESTING05/02/201149000

108216ED SEIZURE PRECAUTIONS05/09/201149000

108220ED INVASIVE VITALS05/09/201149000

108229ED RAPID INFUSER05/11/201149000

108231ED XRAY05/11/201149000

108232ED ULTRASOUND05/11/201149000

108233ED CT05/11/201149000

108234ED BLOOD CULTURE05/11/201149000

108235ED COMPLEX WOUND CARE05/11/201149000

108236ED SIMPLE WOUND CARE05/11/201149000

108237ED AIRWAY05/11/201149000

108238ED OTHER PROCEDURE05/11/201149000

108241ED AIRBORNE ISOLATION05/11/201149000

108242ED DROPLET ISOLATION05/11/201149000

108245ED ADMITS/TRANSFERS05/11/201149000

108246ED ESCORT FOR TESTING05/11/201149000

108249ED NEUTROPENIC ISOLATION05/12/201149000

108250ED VASCULAR ACCESS05/12/201149000

108251ED INTRAOSSEOUS05/12/201149000

108252ED GC SWAB05/12/201149000

108253ED STRAIGHT CATH05/12/201149000

108255ED PEAK FLOW05/12/201149000

108256ED TRAUMA LEVEL05/12/201149000

108262ED SEDATION05/13/201149000

108315ED PHOTO DOCUMENTATION05/19/201149000

108326ED BLOOD BANK05/20/201149000

108327ED URINE05/20/201149000

108328ED TRAY SET UP05/20/201149000

108329ED SALINE LOCK05/20/201149000

108396ED SPLINT APPLICATION06/01/201149000

108427ED SITTER06/06/201149000

108568ED ARTERIAL LINE06/27/201149000

108569ED CVP06/27/201149000

108570ED INTERCRAINIAL06/27/201149000

108571ED PERITONEAL DIALYSIS06/27/201149000

108776ED BIRTH07/27/201149000

108876ED IV GUIDANCE08/17/201149000

109335ED CATH10/07/201149000

109351ED MED ROUTES II10/10/201149000

109352ED MED ROUTES III10/10/201149000

100335ED MED ROUTES01/28/200749000

109838ED POCT GLUCOSE01/23/201249000

109922ED BLADDER SCAN02/13/201249000

130917ED INSTRUCTED ON DEVICE06/06/201249000

131905ED SECLUSION02/11/201349000

Chronicles: #LAST_ROW

info

CER Export Summary

Exported from.............OSU POC

Created by................KOTHE, NEAL

Time created..............10/12/2015 1:24 PM EDT

Time to write file........0 min. 0 sec.

Output file path........../home/koth01/cer.xml

Import specification......CER,1000-TEMPLATE - RULES

Records exported..........50

Items exported............4

Spreadsheet rows..........55

Spreadsheet columns.......5

Export SR items...........Yes

Export MR items...........Yes

MR data in single row.....Yes

Explicit ...........No

Category validation.......No

Export category names.....Yes

INI validation............No

Export INI names..........No

Protect sheet structure...No

Sheet3

record idRule NameCharge Rule Description# of points per actionCumulative?

100336ED VITALS SCORENumber of times a set(2 or more) vitals are entered up to a total of 8 times(80 points max)10yes

100303ED DISPOPoints based on the patient ed discharge disposition of ambulatory1no

100303ED DISPOPoints based on the patient ed discharge disposition AMA30no

100303ED DISPOPoints based on the patient ed discharge disposition ambulance100no

100303ED DISPOPoints based on the patient ed discharge disposition wheelchair30no

100285ED MEANS OF ARRIVALPoints based on the patient's arrival method of Police30no

100285ED MEANS OF ARRIVALPoints based on the patient's arrival method of Private Ambulance30no

100285ED MEANS OF ARRIVALPoints based on the patient's arrival method of Air30no

100285ED MEANS OF ARRIVALPoints based on the patient's arrival method of Hospital Transport30no

100285ED MEANS OF ARRIVALPoints based on the patient's arrival method of Other5no

100285ED MEANS OF ARRIVALPoints based on the patient's arrival method of Private Vehicle1no

100285ED MEANS OF ARRIVALPoints based on the patient's arrival method of Taxi1no

100285ED MEANS OF ARRIVALPoints based on the patient's arrival method of Public Transport1no

100285ED MEANS OF ARRIVALPoints based on the patient's arrival method of EMS30no

100285ED MEANS OF ARRIVALPoints based on the patient's arrival method Wheelchair10no

100285ED MEANS OF ARRIVALPoints based on the patient's arrival method State Vehicle30no

100320ED BEHAVIORAL RESTRAINTSPoints based on the patient's documentation of restraint order300no

100340ED ASSISTIVE DEVICEPoints based on the patient's documentation of assistive devices5no

102499ED DISCHARGE TEACHINGPoints bases on the patient's documentation of simple/moderate teaching1no

102499ED DISCHARGE TEACHINGPoints bases on the patient's documentation of complex teaching30no

107796ED CARDIAC MONITORINGPoints bases on the patient's documentation of 3 lead monitoring100no


107797ED ENEMAPoints bases on the patient's documentation of enema type100no

102501ED WOUND CAREPoints bases on the patient's documentation of negative pressure wound30no

102501ED WOUND CAREPoints bases on the patient's documentation of negative pressure setting30no

102501ED WOUND CAREPoints bases on the patient's documentation of wound packing10no

102501ED WOUND CAREPoints bases on the patient's documentation of dressing wound10no

102501ED WOUND CAREPoints bases on the patient's documentation wound irrigation10no

102501ED WOUND CAREPoints bases on the patient's documentation wound interventions10no

102653ED PELVIC EXAMPoints bases on the patient's documentation of pelvic exam chaperoned30no

102639ED CAST APPLICATIONPoints bases on the patient's documentation any cast type10no

102646ED EYE IRRIGATIONPoints bases on the patient's documentation of eye irrigation fluid30no

107804ED EAR IRRIGATIONPoints bases on the patient's documentation type of irrigant used30no

107805ED INCONTINENCE CAREPoints bases on the patient's documentation of bladder or bowel incontinence30no

102651ED HYPO/HYPERTHERMIAPoints bases on the patient's documentation of hypothermia or hyperthermia3000no

107850ED PACERPoints bases on the patient's documentation of pacer placement location3000no

107967ED FHTPoints bases on the patient's documentation of fetal movement30no

102647ED VISUAL ACUITYPoints bases on the patient's documentation left visual acuity10no

102647ED VISUAL ACUITYPoints bases on the patient's documentation right visual acuity10no

102647ED VISUAL ACUITYPoints bases on the patient's documentation bilateral visual acuity10no

Rule NameCharge Rule Description# of points per actionCumulative?

107971ED CHEST TUBEPoints bases on the patient's documentation of a chest tube300no

108032ED CONTACT ISOLATIONPoints bases on the patient's documentation of contact isolation initiated100no

108032ED CONTACT ISOLATIONPoints bases on the patient's documentation of contact isolation maintained100no

108038ED IV INSERTIONPoints bases on the patient's documentation of preripheral iv insertion100yes

108084ED LABPoints bases on the patient's documentation of a lab hold30yes

108084ED LABPoints bases on the patient's documentation of a venipuncture performed30yes

102661ED O2 DEVICEPoints bases on the patient's documentation of an O2 device100no

108089ED VENTPoints bases on the patient's documentation of type of vent3000no

108090ED IMMUNIZATIONPoints bases on the patient's documentation of immunization teaching30no

108092ED NGTPoints bases on the patient's documentation of naso/oral tube30no

108104ED L&DPoints bases on the patient's documentation send patient to L&D from triage30no

108122ED EKGPoints bases on the patient's documentation of a 12 lead ECG30no

108130ED NON VIOLENT RESTRAINTPoints bases on the patient's documentation of non-violent restraint type100no

108131ED VIOLENT RESTRAINTPoints bases on the patient's documentation of violent restraint type300no

108168ED POCT RAPID STREP APoints bases on the patient's completed POCT procedure order of rapid strep order10no

108171ED POCT OCCULT BLOOD STOOLPoints bases on the patient's completed POCT procedure order of occult blood stool10no

108216ED SEIZURE PRECAUTIONSPoints bases on the patient's documentation seizure precautions30no

108220ED INVASIVE VITALSPoints bases on the patient's documentation of central venous pressure3000no

108220ED INVASIVE VITALSPoints bases on the patient's documentation of mixed venous oxygenation3000no

108220ED INVASIVE VITALSPoints bases on the patient's documentation of central venous saturation3000no

108229ED RAPID INFUSERPoints bases on the patient's documentation rapid infuser3000no

108231ED XRAYPoints bases on the patient's order of xray10yes

108232ED ULTRASOUNDPoints bases on the patient's documentation of returning from ultrasound10yes

108233ED CTPoints bases on the patient's documentation of returning from CT100yes

108234ED BLOOD CULTUREPoints bases on the patient's documentation of blood cultures being sent to the lab100yes

108237ED AIRWAYPoints bases on the patient's documentation of airway300no

108238ED OTHER PROCEDUREPoints bases on the patient's documentation of a procedure not accounted100no

108241ED AIRBORNE ISOLATIONPoints bases on the patient's documentation of airborn isolation initiated30no

108241ED AIRBORNE ISOLATIONPoints bases on the patient's documentation of airborn isolation maintained30no

108242ED DROPLET ISOLATIONPoints bases on the patient's documentation of droplet isolation initiated30no

108242ED DROPLET ISOLATIONPoints bases on the patient's documentation of droplet isolation maintained30no

108245ED ADMITS/TRANSFERSPoints bases on the patient's documentation of transfer to OSU ER30no

108245ED ADMITS/TRANSFERSPoints bases on the patient's documentation of transfer to L&D after ER treatment30no

108245ED ADMITS/TRANSFERSPoints bases on the patient's documentation of transfer to outside facility as direct admit300no

108245ED ADMITS/TRANSFERSPoints bases on the patient's documentation of med surg admit100no

108245ED ADMITS/TRANSFERSPoints bases on the patient's documentation of telemetry admit300no

108245ED ADMITS/TRANSFERSPoints bases on the patient's documentation of psych bed admit100no

108245ED ADMITS/TRANSFERSPoints bases on the patient's documentation of OR admit300no

108245ED ADMITS/TRANSFERSPoints bases on the patient's documentation of ICU admit3000no

108246ED ESCORT FOR TESTINGPoints bases on the patient's documentation of monitored escort for testing300no

108249ED NEUTROPENIC ISOLATIONPoints bases on the patient's documentation of neutropenic precautions initiated10no

108249ED NEUTROPENIC ISOLATIONPoints bases on the patient's documentation of neutropenic precautions maintained10no

108250ED VASCULAR ACCESSPoints bases on the patient's documentation of single/double lumen port300no


108251ED INTRAOSSEOUSPoints bases on the patient's documentation of intraosseous insertion300no

108253ED STRAIGHT CATHPoints bases on the patient's documentation of intermittent cath30no

108255ED PEAK FLOWPoints bases on the patient's documentation of peak flow treatment30no

108256ED TRAUMA LEVELPoints bases on the patient's documentation of any trauma level3000no

108315ED PHOTO DOCUMENTATIONPoints bases on the patient's documentation of photo evidence collection100no

108326ED BLOOD BANKPoints bases on the patient's completion of blood bank orders100no

108327ED URINEPoints bases on the patient's order of random creatinine urine30no

108328ED TRAY SET UPPoints bases on the patient's order of tray set up10no

108329ED SALINE LOCKPoints bases on the patient's order of saline lock30no

108396ED SPLINT APPLICATIONPoints bases on the patient's documentation a splint/brace30no

108427ED SITTERPoints bases on the patient's documentation of ED sitter300no

108568ED ARTERIAL LINEPoints bases on the patient's documentation of arterial line insertion3000no

108570ED INTARCRAINIALPoints bases on the patient's documentation of intracanial pressure3000no

108571ED PERITONEAL DIALYSISPoints bases on the patient's documentation of peritoneal dialysis300no

108776ED BIRTHPoints bases on the patient's documentation of ED birth300no

108876ED IV GUIDANCEPoints bases on the patient's documentation of ultrasound or vein mapping guidance300no

109335ED CATHPoints bases on the patient's documentation of indwelling catheter30yes

109351ED MED ROUTES IIPoints bases on the patient's medication administered via subq30yes

109351ED MED ROUTES IIPoints bases on the patient's medication administered via infiltration30yes

109351ED MED ROUTES IIPoints bases on the patient's medication administered via IM30no

109352ED MED ROUTES IIIPoints bases on the patient's medication administered via brain cath100yes

109352ED MED ROUTES IIIPoints bases on the patient's medication administered via intratumoral100yes

109352ED MED ROUTES IIIPoints bases on the patient's medication administered via intracameral100yes

109352ED MED ROUTES IIIPoints bases on the patient's medication administered via nebulization100no

109352ED MED ROUTES IIIPoints bases on the patient's medication administered via intraosseous100yes

109352ED MED ROUTES IIIPoints bases on the patient's medication administered via intravenous100no

100335ED MED ROUTESPoints bases on the patient's medication administered via oral10yes

100335ED MED ROUTESPoints bases on the patient's medication administered via intranasal10yes

100335ED MED ROUTESPoints bases on the patient's medication administered via both ears10yes

100335ED MED ROUTESPoints bases on the patient's medication administered via left ear10yes

100335ED MED ROUTESPoints bases on the patient's medication administered via right ear10yes

100335ED MED ROUTESPoints bases on the patient's medication administered via both eyes10yes

100335ED MED ROUTESPoints bases on the patient's medication administered via right eye10yes

100335ED MED ROUTESPoints bases on the patient's medication administered via insuffilation10yes

100335ED MED ROUTESPoints bases on the patient's medication administered via topical10yes

100335ED MED ROUTESPoints bases on the patient's medication administered via sublingual10yes

100335ED MED ROUTESPoints bases on the patient's medication administered via Per NG tube10yes

100335ED MED ROUTESPoints bases on the patient's medication administered via Transdermal10yes

100335ED MED ROUTESPoints bases on the patient's medication administered via Peg Tube10yes

100335ED MED ROUTESPoints bases on the patient's medication administered via Inhalation10yes

109838ED POCT GLUCOSEPoints bases on the patient's documentation of POCT Glucose10yes

109922ED BLADDER SCANPoints bases on the patient's documentation of bladder scanning device30yes

130917ED INSTRUCTED ON DEVICEPoints bases on the patient's documentation ortho device teaching30no

131905ED SECLUSIONPoints bases on the patient's documentation of seclusion300no

New Charging Methodology

Rule Name Charge Rule Description # of points per action Cumulative?ED CHEST TUBE Points bases on the patient's documentation of a chest tube 300 noED CONTACT ISOLATION Points bases on the patient's documentation of contact isolation initiated 100 noED CONTACT ISOLATION Points bases on the patient's documentation of contact isolation maintained 100 noED IV INSERTION Points bases on the patient's documentation of preripheral iv insertion 100 yesED LAB Points bases on the patient's documentation of a lab hold 30 yesED LAB Points bases on the patient's documentation of a venipuncture performed 30 yesED O2 DEVICE Points bases on the patient's documentation of an O2 device 100 noED VENT Points bases on the patient's documentation of type of vent 3000 noED IMMUNIZATION Points bases on the patient's documentation of immunization teaching 30 noED NGT Points bases on the patient's documentation of naso/oral tube 30 noED L&D Points bases on the patient's documentation send patient to L&D from triage 30 noED EKG Points bases on the patient's documentation of a 12 lead ECG 30 noED NON VIOLENT RESTRAINT Points bases on the patient's documentation of non-violent restraint type 100 noED VIOLENT RESTRAINT Points bases on the patient's documentation of violent restraint type 300 noED POCT RAPID STREP A Points bases on the patient's completed POCT procedure order of rapid strep order 10 noED POCT OCCULT BLOOD STOOL Points bases on the patient's completed POCT procedure order of occult blood stool 10 noED SEIZURE PRECAUTIONS Points bases on the patient's documentation seizure precautions 30 noED INVASIVE VITALS Points bases on the patient's documentation of central venous pressure 3000 noED INVASIVE VITALS Points bases on the patient's documentation of mixed venous oxygenation 3000 noED INVASIVE VITALS Points bases on the patient's documentation of central venous saturation 3000 noED RAPID INFUSER Points bases on the patient's documentation rapid infuser 3000 noED XRAY Points bases on the patient's order of xray 10 yesED ULTRASOUND Points bases on the patient's documentation of returning from ultrasound 10 yesED CT Points bases on the patient's documentation of returning from CT 100 yesED BLOOD CULTURE Points bases on the patient's documentation of blood cultures being sent to the lab 100 yesED AIRWAY Points bases on the patient's documentation of airway 300 noED OTHER PROCEDURE Points bases on the patient's documentation of a procedure not accounted 100 noED AIRBORNE ISOLATION Points bases on the patient's documentation of airborn isolation initiated 30 noED AIRBORNE ISOLATION Points bases on the patient's documentation of airborn isolation maintained 30 noED DROPLET ISOLATION Points bases on the patient's documentation of droplet isolation initiated 30 noED DROPLET ISOLATION Points bases on the patient's documentation of droplet isolation maintained 30 noED ADMITS/TRANSFERS Points bases on the patient's documentation of transfer to OSU ER 30 noED ADMITS/TRANSFERS Points bases on the patient's documentation of transfer to L&D after ER treatment 30 noED ADMITS/TRANSFERS Points bases on the patient's documentation of transfer to outside facility as direct admit 300 noED ADMITS/TRANSFERS Points bases on the patient's documentation of med surg admit 100 noED ADMITS/TRANSFERS Points bases on the patient's documentation of telemetry admit 300 noED ADMITS/TRANSFERS Points bases on the patient's documentation of psych bed admit 100 noED ADMITS/TRANSFERS Points bases on the patient's documentation of OR admit 300 noED ADMITS/TRANSFERS Points bases on the patient's documentation of ICU admit 3000 noED ESCORT FOR TESTING Points bases on the patient's documentation of monitored escort for testing 300 noED NEUTROPENIC ISOLATION Points bases on the patient's documentation of neutropenic precautions initiated 10 noED NEUTROPENIC ISOLATION Points bases on the patient's documentation of neutropenic precautions maintained 10 noED VASCULAR ACCESS Points bases on the patient's documentation of single/double lumen port 300 no

CER export

1






Not a category item






Rule ID







100336ED VITALS SCORE01/28/200749000

100303ED DISPO01/17/200749000






107797ED ENEMA03/25/201149000

102501ED WOUND CARE05/13/200949000

102653ED PELVIC EXAM05/13/200949000






107850ED PACER03/31/201149000

107967ED FHT04/11/201149000

102647ED VISUAL ACUITY05/13/200949000

107971ED CHEST TUBE04/11/201149000


108038ED IV INSERTION04/19/201149000

108084ED LAB04/21/201149000

102661ED O2 DEVICE05/13/200949000

108089ED VENT04/21/201149000

108090ED IMMUNIZATION04/21/201149000

108092ED NGT04/21/201149000

108104ED L&D04/21/201149000

108122ED EKG04/25/201149000





108173ED POCT TESTING05/02/201149000



108229ED RAPID INFUSER05/11/201149000

108231ED XRAY05/11/201149000

108232ED ULTRASOUND05/11/201149000

108233ED CT05/11/201149000

108234ED BLOOD CULTURE05/11/201149000



108237ED AIRWAY05/11/201149000








108251ED INTRAOSSEOUS05/12/201149000

108252ED GC SWAB05/12/201149000

108253ED STRAIGHT CATH05/12/201149000

108255ED PEAK FLOW05/12/201149000

108256ED TRAUMA LEVEL05/12/201149000

108262ED SEDATION05/13/201149000


108326ED BLOOD BANK05/20/201149000

108327ED URINE05/20/201149000

108328ED TRAY SET UP05/20/201149000

108329ED SALINE LOCK05/20/201149000


108427ED SITTER06/06/201149000

108568ED ARTERIAL LINE06/27/201149000

108569ED CVP06/27/201149000



108776ED BIRTH07/27/201149000

108876ED IV GUIDANCE08/17/201149000

109335ED CATH10/07/201149000

109351ED MED ROUTES II10/10/201149000

109352ED MED ROUTES III10/10/201149000

100335ED MED ROUTES01/28/200749000

109838ED POCT GLUCOSE01/23/201249000

109922ED BLADDER SCAN02/13/201249000


131905ED SECLUSION02/11/201349000


info

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New Charging Methodology Rule Name Charge Rule Description # of points per action Cumulative?

ED INTRAOSSEOUS Points bases on the patient's documentation of intraosseous insertion 300 noED STRAIGHT CATH Points bases on the patient's documentation of intermittent cath 30 noED PEAK FLOW Points bases on the patient's documentation of peak flow treatment 30 noED TRAUMA LEVEL Points bases on the patient's documentation of any trauma level 3000 noED PHOTO DOCUMENTATION Points bases on the patient's documentation of photo evidence collection 100 noED BLOOD BANK Points bases on the patient's completion of blood bank orders 100 noED URINE Points bases on the patient's order of random creatinine urine 30 noED TRAY SET UP Points bases on the patient's order of tray set up 10 noED SALINE LOCK Points bases on the patient's order of saline lock 30 noED SPLINT APPLICATION Points bases on the patient's documentation a splint/brace 30 noED SITTER Points bases on the patient's documentation of ED sitter 300 noED ARTERIAL LINE Points bases on the patient's documentation of arterial line insertion 3000 noED INTARCRAINIAL Points bases on the patient's documentation of intracanial pressure 3000 noED PERITONEAL DIALYSIS Points bases on the patient's documentation of peritoneal dialysis 300 noED BIRTH Points bases on the patient's documentation of ED birth 300 noED IV GUIDANCE Points bases on the patient's documentation of ultrasound or vein mapping guidance 300 noED CATH Points bases on the patient's documentation of indwelling catheter 30 yesED MED ROUTES II Points bases on the patient's medication administered via subq 30 yesED MED ROUTES II Points bases on the patient's medication administered via infiltration 30 yesED MED ROUTES II Points bases on the patient's medication administered via IM 30 noED MED ROUTES III Points bases on the patient's medication administered via brain cath 100 yesED MED ROUTES III Points bases on the patient's medication administered via intratumoral 100 yesED MED ROUTES III Points bases on the patient's medication administered via intracameral 100 yesED MED ROUTES III Points bases on the patient's medication administered via nebulization 100 noED MED ROUTES III Points bases on the patient's medication administered via intraosseous 100 yesED MED ROUTES III Points bases on the patient's medication administered via intravenous 100 noED MED ROUTES Points bases on the patient's medication administered via oral 10 yesED MED ROUTES Points bases on the patient's medication administered via intranasal 10 yesED MED ROUTES Points bases on the patient's medication administered via both ears 10 yesED MED ROUTES Points bases on the patient's medication administered via left ear 10 yesED MED ROUTES Points bases on the patient's medication administered via right ear 10 yesED MED ROUTES Points bases on the patient's medication administered via both eyes 10 yesED MED ROUTES Points bases on the patient's medication administered via right eye 10 yesED MED ROUTES Points bases on the patient's medication administered via insuffilation 10 yesED MED ROUTES Points bases on the patient's medication administered via topical 10 yesED MED ROUTES Points bases on the patient's medication administered via sublingual 10 yesED MED ROUTES Points bases on the patient's medication administered via Per NG tube 10 yesED MED ROUTES Points bases on the patient's medication administered via Transdermal 10 yesED MED ROUTES Points bases on the patient's medication administered via Peg Tube 10 yesED MED ROUTES Points bases on the patient's medication administered via Inhalation 10 yesED POCT GLUCOSE Points bases on the patient's documentation of POCT Glucose 10 yesED BLADDER SCAN Points bases on the patient's documentation of bladder scanning device 30 yesED INSTRUCTED ON DEVICE Points bases on the patient's documentation ortho device teaching 30 noED SECLUSION Points bases on the patient's documentation of seclusion 300 no

CER export

1






Not a category item






Rule ID







100336ED VITALS SCORE01/28/200749000

100303ED DISPO01/17/200749000






107797ED ENEMA03/25/201149000

102501ED WOUND CARE05/13/200949000

102653ED PELVIC EXAM05/13/200949000






107850ED PACER03/31/201149000

107967ED FHT04/11/201149000

102647ED VISUAL ACUITY05/13/200949000

107971ED CHEST TUBE04/11/201149000


108038ED IV INSERTION04/19/201149000

108084ED LAB04/21/201149000

102661ED O2 DEVICE05/13/200949000

108089ED VENT04/21/201149000

108090ED IMMUNIZATION04/21/201149000

108092ED NGT04/21/201149000

108104ED L&D04/21/201149000

108122ED EKG04/25/201149000





108173ED POCT TESTING05/02/201149000



108229ED RAPID INFUSER05/11/201149000

108231ED XRAY05/11/201149000

108232ED ULTRASOUND05/11/201149000

108233ED CT05/11/201149000

108234ED BLOOD CULTURE05/11/201149000



108237ED AIRWAY05/11/201149000








108251ED INTRAOSSEOUS05/12/201149000

108252ED GC SWAB05/12/201149000

108253ED STRAIGHT CATH05/12/201149000

108255ED PEAK FLOW05/12/201149000

108256ED TRAUMA LEVEL05/12/201149000

108262ED SEDATION05/13/201149000


108326ED BLOOD BANK05/20/201149000

108327ED URINE05/20/201149000

108328ED TRAY SET UP05/20/201149000

108329ED SALINE LOCK05/20/201149000


108427ED SITTER06/06/201149000

108568ED ARTERIAL LINE06/27/201149000

108569ED CVP06/27/201149000



108776ED BIRTH07/27/201149000

108876ED IV GUIDANCE08/17/201149000

109335ED CATH10/07/201149000

109351ED MED ROUTES II10/10/201149000

109352ED MED ROUTES III10/10/201149000

100335ED MED ROUTES01/28/200749000

109838ED POCT GLUCOSE01/23/201249000

109922ED BLADDER SCAN02/13/201249000


131905ED SECLUSION02/11/201349000


info

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New Charging Methodology

*No level of service for sexual assault exam

Points Level of Service* 0 to 10 Level 1 11 to 30 Level 2 31 to 99 Level 3 100 to 299 Level 4 300 to 2999 Level 5 3000+ Critical Care

IT and Nursing Integration 1. Coordinated the implementation of documentation and levels of

service to be charged. 2. Reviewed one week of patient charts from each ED, which totaled

642 charts, and compared their charges to charges calculated based on proposed levels and point assignments.

3. Tested on paper and in the EMR before implementation (160 hours).

4. Verified that the charges were compliant.

The New Tool: Embedded • Example of documenting means of arrival.

The New Tool: Embedded • Charging is now embedded in the normal nursing workflow. Every

patient is assigned a level of service.

How it Works

• Assigned Level is visible as points accumulate • Points drop as care is documented • Total point value is continually updated. The final total reflects a level. • Upon accepting in tool the level is automatically selected in the

charge capture tool.

Where Charges Appear

Post Live Governance • Daily reports ran post live for three weeks until the data normalized.

– Revenue continually monitoring by business office and clinical areas.

– Meetings by group to review possible changes when necessary.

• Susceptibilities – Decrease in throughput – Charting discrepancies

Post Live Governance • Upgrade Testing

– Content Management

• Adaptability – Ability to quickly make changes and test on real data as needs

arise

• Implemented at our Community Connect site in April 2013 and shared with other Epic organizations.

Pre Live Data

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

ED Level 1 ED Level 2 ED Level 3 ED Level 4 ED Level 5 ED CC

Pre Live

U.S. Ave 2010

Testing Results

7

26 23

46

11

3 2 2

30

45

34

3 1 2

34

39 37

3 0

5

10

15

20

25

30

35

40

45

50

Level 1 Level 2 Level 3 Level 4 Level 5 CCED Level 1 ED Level 2 ED Level 3 ED Level 4 ED Level 5 ED CC

Blue (diamonds): Previous LOS Red (squares): Paper testing Orange (squares): Electronic testing

Actual Results – 4 Months Post Live

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

ED LEVEL 1 ED LEVEL 2 ED LEVEL 3 ED LEVEL 4 ED LEVEL 5 ED CC

ED Levels System Impact Nov 11 - Feb 12

SMS

ASAPEpic

Legacy

Sustainability

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

ED Level 1 ED Level 2 ED Level 3 ED Level 4 ED Level 5 ED CC

U.S. Ave 2014

AMC Ave 2014

Pre-Live

2012

2013

2014

2015

Financial Considerations • Labor costs: $54,480.

– Conceptualization, build, and testing performed by staff

With improved Level of Service assignment, our gross revenue increase has been about $50 million per year.

Year Volume Dollar % Increase

From Pre-Live Volume % Increase

From Pre Live Pre-Live 107,458 - -

2012 118,022 39% 10% 2013 114,688 41% 7% 2014 115,922 42% 8% 2015 124,144 49% 16%

Questions Neal Kothe

640 Ackerman Rd. Columbus, OH 43202

[email protected]

Carol Gray MSN, RN, CCRN, CEN SANE-A 1492 E Broad St.

Columbus, OH 43205 [email protected]

mailto:[email protected]

Developing an ED Facility Charge Calculator�March 3, 2016 4:00pmConflict of InterestAgendaLearning ObjectivesSlide Number 5Local Problem and Intended ImprovementIntended ImprovementsAlternative SolutionDeveloping the Charging RulesDeveloping the Charging RulesOld Charging MethodologiesNew Charging MethodologyNew Charging MethodologyNew Charging MethodologyNew Charging MethodologyIT and Nursing IntegrationThe New Tool: EmbeddedThe New Tool: EmbeddedHow it WorksWhere Charges AppearPost Live Governance Post Live Governance Pre Live DataTesting ResultsActual Results – 4 Months Post LiveSustainabilityFinancial ConsiderationsQuestions

Documents

Developing an ED Facility Charge Calculator March 3, 2016 ...€¦ · Developing an ED Facility Charge Calculator March 3, 2016 4:00pm Neal Kothe, The Ohio State University Wexner