STRATEGIES FOR ENHANCING

CLINICAL DOCUMENTATION & PROCESSES

TO OPTIMIZE REIMBURSEMENT

Northeast Ohio HFMA Physician Summit Series

October 24, 2017

Christina Janus, MBA, RHIA

Director, Health Information Management, The MetroHealth System

Jaclyn Woolnough, CPMA, CRCR

Director, Revenue Integrity, The MetroHealth System

The following report is proprietary information and constitutes trade secrets of The MetroHealth System and may

not be disclosed in whole or part to any external parties without the express consent of The MetroHealth System.

This document is intended to be used internally for MetroHealth System discussion.

Today’s Objectives

• Discuss how clinicians, the revenue cycle and information

technology collaborate to improve workflow and clinical

documentation to optimize reimbursement

• Outline the importance of maintaining higher levels of clinical

documentation specificity & accuracy for improved value and

to mitigate risks

• Discuss the importance of Revenue Integrity, areas to target

and considerations for a Population Health World

• Explore best practices on how the use of revenue cycle

metrics, clinical data, and ongoing education to improve

productivity, financial performance and clinical outcomes

Why is the quality and timeliness of provider

medical record documentation important?

• Continuity of patient care & official business record

• Tells a patient’s story

• Documentation of healthcare services provided

• Proves standards of care are being followed as required by governing bodies

• Medical necessity

• Supports what was done and why:

– Patient’s clinical presentation

– Past and current medical history

– Laboratory and other diagnostic studies

– Medications

– Response to treatment

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Why is the quality and timeliness of provider

documentation important?

• Medical coding and billing accuracy

• The diagnostic and procedural codes assigned are based on what the record state

• Payment for services rendered are based on codes provided for billing

• Not Documented = NOT DONE!

• Documentation audits and reviews

• Random vs. Focused

• Compliance vs. Coding vs. Billing

• Internal vs. External

• Legal ramifications

• Prove what care was provided

• Support rational for actions taken or decisions not to take additional action

• Serves as the provider’s memory

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INPATIENT CLINICAL DOCUMENTATION &

REIMBURSEMENT

What is CDI?

• CDI = Clinical Documentation Improvement

• The goal CDI is for complete and accurate documentation of

diagnosis and procedures in the medical record to reflect:

• The patient’s true Severity of Illness

• The patient’s Risk of Mortality

• Accurate Physician & Hospital Quality Profiles

• Optimize the CMI (Case Mix Index)

CMS MS-DRG System

• Relative Weight (wt): Each MS-DRG is assigned a relative weight. This weight

reflects the expected resource consumption and severity of diagnoses within the

MS-DRG and is constant from hospital to hospital.

• Blended Rate: Each hospital is assigned a “blended rate” based on a formula

that includes location, services provided etc. The blended rate varies from

hospital to hospital.

• Reimbursement: Reimbursement is calculated by multiplying the relative weight

by the blended rate.

– Example: Relative weight 0.6618 x blended rate of $4,500 = $2,978.10 reimbursement.

What Determines the MS-DRG?

The MS-DRG is determined by:

• Principle Diagnosis: The condition established after study to be chiefly responsible

for occasioning the admission. Must be Present On Admission (POA) and meet

admission criteria.

• Procedures Performed during the hospitalization

• Complications: A condition that arises during the hospital stay which prolongs the

length of stay. It does not necessarily represent an error in medical care.

• Comorbidities: Pre-existing condition, may be POA, but not the reason for admission.

• Patient age and gender

• Discharge Disposition

Case Mix Index (CMI)

Case Mix Index: The average of all the relative weights of all the MS-DRGs in

a patient population in a given time period.

Example:

CMI Formula: Add all the relative weights and divide by 5.

CMI for this Population is: 2.06506

Description MS-DRG Relative

Weight

1. Heart Failure w/CC 292 0.9707

2. Cholecystectomy w/CC 415 2.0071

3. Sepsis w/ Mechanical Ventilator for

96+ hours

870 5.8782

4. Chest Pain 313 0.6621

5. TURP (Transurethral resection of the

prostate) w/o cc/mcc

714 0.8072

Complication/Comorbidity (CC)

Major Complication/Comorbidity (MCC)

Medicare has designated a number of diagnoses as reimbursable CCs and

MCCs.

• Common MCCs:

• Acute Respiratory Failure

• ESRD

• Encephalopathy

• Pneumonia

• Pressure ulcer – Stage III and IV

• Sepsis

• Shock

• Malnutrition - Severe

• Common CCs:

• Acute Renal Failure

• CKD (Chronic Kidney Disease) stage IV or V

• Hyponatremia/Hypernatremia

• Ileus

• Pleural Effusion

• UTI

• Malnutrition (mild, moderate,

unspecified)

MCC/CC Impact on MS-DRGs

Patient A Patient B Patient C Patient D

PDx: Viral Pneumonia Viral Pneumonia Viral Pneumonia Viral pneumonia

Comorbidities: None Malnutrition (CC) None Acute Respiratory

Failure (MCC)

Complications: None None Hyponatremia

(CC)

AMI (MCC)

MS-DRG 195 w/o CC/MCC 194 w/CC 194 w/cc 193 w/MCC

Relative Weight: 0.7111 0.9695 0.9695 1.4261

Underlying Principle of 3M™ APR DRGs

Severity of illness (SOI) and risk of

mortality (ROM) are dependent on

the patient’s underlying problem.

High severity of illness and risk of

mortality are characterized by multiple

serious diseases and the interaction

among those diseases.

SOI and ROM are Independent

The severity of illness and risk of mortality subclass are

calculated separately and may be different from each other.

Severity of Illness is a weight base

ROM is based on many factors including age & gender

ROM = 1

Low risk of

mortality

Major severity

of illness

SOI = 3

Acute

Cholecystitis

Impact of Secondary Diagnoses on

SOI and ROM

ROM = 1

Minor risk

of

mortality

Major

severity

of illness

SOI = 3

Acute

CholecystitisPeritonitis

ROM = 2

Moderate

risk of

mortality

Major

severity

of

illness

SOI = 3

3M™ APR DRG Assignment is Driven by:

• Principal diagnosis

• Procedures performed

• All secondary diagnoses

• Interaction between principal and secondary diagnoses

• Age

• Gender

Example of Progression of Severity of Illness Subclass

Severity

Of Illness

Secondary Diagnosis of

Diabetes Mellitus

1 Minor Uncomplicated Diabetes

2 Moderate Diabetes with Renal

Manifestation

3 Major Diabetes with Ketoacidosis

4 Severe Diabetes with Hyperosmolar

Coma

Example of Progression of Risk of Mortality Subclass

Risk of

Mortality

Secondary Diagnosis of

Cardiac Arrhythmias

1 Minor Premature beats

2 Moderate Sinoatrial Node Dysfunction

3 Major Paroxysmal Ventricular

Tachycardia

4 Severe Ventricular Fibrillation

Monitoring Clinical Documentation Improvement – Key

Performance Indicators

Overall CMI Medical CMI Surgical CMI

CMI by Service Line MCC / CC Capture Rate

Medical & Surgical

Cases (influences CMI)

Alternative Principal

Diagnosis Ratios &

Opportunities

CDI Coverage Rates CDI Query Rates Financial Impact

Related to Physician

Queries

Physician Response

Rate Related to

Queries

Signs & Symptom /

Lower-Weighted DRGs

Comparison to

MedPAR 80th Percentile

Performance

OPTIMIZING REIMBURSEMENT

THROUGH A STRATEGIC

REVENUE INTEGRITY

PROGRAM

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Overview of Revenue Integrity

• Hospitals nationwide are experiencing a reduction in reimbursement from

government payors, as well as reduced utilization of some high dollar services

(i.e., inpatient).

• Most hospitals will respond with cost cutting measures.

• Fewer staff to manage more complexity.

A revenue integrity departments goal is to ensure that all

revenue is created, captured, coded, priced, and paid

correctly within compliance guidelines.

• Revenue integrity can be achieved only with the proper processes, tools, and

related expertise aimed at effectively pricing, charging, and coding for services

and supplies related to patient care.

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Scheduling Registration Certification

Financial Counseling

Encounter Charge Capture

and Coding

Utilization Review

Medical Record Documentation

Claims Submission

Third Party Follow Up

Rejection Processing

Payment Posting

Appeals

Contract Management

Key Target Areas

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• An audit of each providers evaluation and management

services is completed at least once a year.

• New providers

• High Dollar Infusions/injections

• Surgical procedures

• Metro Life Flight

• Procedures

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Are you being reimbursed for the

services you provide?

Can you identify missing revenues?

What percentage of your claims are

rejected or denied?

Are there charges that do not pass from the clinical

system to the billing system?

How often does your organization lose money due to

audits and takebacks?

What is your organizations

pattern of denials?

How much additional revenue could you realize?

How often do you sit down with an expert to discuss

opportunities?

Key Questions to Ask

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Yesterday Tomorrow

Risk/Reward

Quality

Population Health

Fee for Service

Quantity

Don’t get paid for it? Don’t do it!

Revenue Integrity in a Population Health World

HCC (Hierarchical Condition Categories)

HCCs

• Risk adjusted model to help healthcare facilities assess

patient health statuses

• This model uses data to prospectively estimate predicated

costs for enrolled members in the ambulatory setting

• Estimates are based on anticipated risks under the

Medicare Advantage capitation payment system

• Opportunity to improve clinical documentation by utilizing

a more accurate method to determine a patient’s condition

which can help determine best care path for patient based

on diagnosis

Medicare Risk Adjustment

Case Study (or, what Medicare doesn’t know can hurt you)

Reality:

A 76 year old woman with Type 2 Diabetes Mellitus with Chronic Renal

Insufficiency, Paroxysmal Atrial Fibrillation (on warfarin), and Breast

Cancer (s/p right mastectomy 15 years ago) presents for a follow up

visit.

Medicare’s view (based on our diagnoses):

A 76 year old woman with uncomplicated Diabetes Mellitus presents

for a follow up visit.

Keeping Score

What the Provider Knows Points What Medicare Knows Points

Female patient 0.437 Female patient 0.437

Diabetes with renal disease -

HCC 19

0.368 Diabetes without

complications - HCC 18

0.118

Breast cancer - HCC 12 0.154

Atrial Fibrillation - HCC 86 0.295

TOTAL 1.254 0.555

Patient is more than twice as complex as Medicare knows

Risk Adjustment Alert in Epic

Tools we have implemented at MetroHealth to assist

providers with HCC documentation:

• Will display if Epic detects the presence of conditions

(from prior visits or the problem list) which have not yet

been billed this calendar year

• Shows provider a list of these conditions as a reminder

to the provider to bill for them if the provider addressed

them

Alert

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Conclusions

• Perform routine medical record reviews & analysis

- Determine opportunity for documentation improvement and target areas

- Determine opportunities for improved medical code and DRG assignment

• Invest in education & training

– Clinical documentation is paramount, being used for medical coding & reimbursement

and is increasingly used to gauge the quality of care provided & public outcomes data

• Choose effective and focused metrics

– What truly makes a difference and measures outcomes?

• Invest in data & information technology

– Revolution in data availability drives how care is delivered, managed and paid

– Healthcare transformation requires taking all of this data and turning it into actionable,

meaningful information

– Ensure systems and tools are optimally utilized and are scalable to a quickly changing

healthcare industry

•

Conclusions

• Focus on collaboration

– Medical providers, revenue cycle, finance & information technology professionals,

executive sponsorship, etc. are all crucial players needed for team success

– Physician Champion role is encouraged for Clinical Documentation Improvement

programs to help facilitate physician participation and support education of

physicians

Questions