Innovation Storyboard

Abu Dhabi

EVALUATION & MANAGEMENT CODING DOCUMENTATION BY PHYSICIANS 

– A PROCESS AND ROLE INNOVATIONJuly ‐ September 2010

NMCSH ‐ AUH

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1. About the Organization

• NMC Specialty Hospital, Abu Dhabi is a multi‐specialty hospitalproviding quality and trusted secondary and tertiary healthcareservices to the people of Abu Dhabi.

• Established in 1975.• ISO 9001: 2008 certified, ISO since 2000• Joint Commission International (JCI) accredited – May 2010• Average Out patients (OP) visits – 1400• Number of Patient Rooms / beds ‐ 100• Number of ICU Beds ‐ 7• Number of Nursery Beds ‐ 4• Number of Operation Theaters ‐ 7• Number of Doctors ‐ 150• Number of Nurses and Paramedics ‐ 370

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Abu Dhabi

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1. About the Organization (contd.)

2. The Idea

• How was the opportunity for innovation identified? What was the business problem/opportunity?

The Health Authority – Abu Dhabi (HAAD) had made it a requirementthat all healthcare facilities adopt E&M (Evaluation & Management)codes and charges for Out Patient physician consultations. Thehealthcare facilities of Abu Dhabi should be certified by 01st

September 2010 through a 3rd party before they are allowed to do so.

The charges as per the E&M codes, is considerably higher thancurrent charges.

After this date those hospitals who were not certified would only beallowed to charge a flat rate of AED 68, which is the lowest among theproposed E&M rate for all OP visits (irrespective of the insuranceplan). This would be highly unviable option.

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• How was the opportunity for innovation identified? What was the business problem/opportunity? (contd.)

Projected increase of OP visits by 10‐15% in the year 2011 i.e. 1600OP visits

Projected increase of patients covered by insurance is expected toincrease from 90% to 92%

We have adopted E&M coding for OP visits as a part of the missionof the hospital i.e. aligning with the healthcare vision of Abu Dhabi.

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2. The Idea (contd.)

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2. The Idea (contd.)

What preliminary research was carriedout (list sources)?• 1995 Documentation Guidelines For

Evaluation & Management Services

• 1997 Documentation Guidelines ForEvaluation & Management Services

• Evaluation & Management Servicesguide

• Joint Commission InternationalAccreditation Standards for Hospitals,3rd Edition,

• HAAD Hospital Standards, 2008

• Daman Abu Dhabi Plan E & M CodesAnd Prices (Plan with the lowest rates)

S. No New Patient Code  

Charges(in AED)

Established PatientCode

Charges(in AED)

1 99201 126 99211 68

2 99202 219 99212 130

3 99203 321 99213 211

4 99204 492 99214 318

5 99205 620 99215 431

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DAMAN ABU DHABI PLAN E & M CODES AND PRICES

2. The Idea (contd.)

The Daman Abu Dhabi Plan had prices of AED 65, AED 85, AED 122 for Out Patientconsultation with General Practitioner, Specialist and Consultants during thestudy period. This was the lowest among the insurance charges.

• How was the project prioritized?

– The project was given very high priority since it affected the revenue cycle and had a short period for implementation.

– Also, it was required to comply with HAAD regulations.

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2. The Idea (contd.)

Tools/Techniques to generate the  idea 

• Brainstorming 

• Revenue projections

• Project Study

Gap Analysis

Talent assessment

– Two physicians were deputed , they underwent online training and also attended workshops regarding coding conducted by the HAAD.

Competency Assessment

– This was done to assess the understanding of E & M coding  guidelines by the physicians

2. The Idea (contd.)

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2. The Idea (contd.)

Advantages / Disadvantages of various alternatives

Various alternatives were studied and discussed before implementation of the project.

ALTERNATIVE – I  (not undergoing E&M coding certification)

• All types of Outpatient visits would get a flat charge of AED 68(lowest of Daman, Abu Dhabi plan E&M Charges) irrespective of the insurance company or complexity and management the illness

• There would be a 30.79% loss of revenue i.e. AED 16,253,085

• There would also be an opportunity loss of 50.41% i.e.  AED 26,608,865 

• Therefore the net loss would be 81.20% i.e. AED 42,861,950 

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2. The Idea (contd.)

Advantages / Disadvantages of various alternatives

ALTERNATIVE II ‐ E & M Coding by Certified Coders

• Additional revenue generated would be AED 26,608,865 (50.41% )

• Very high costs i.e. additional annual cost for 40 coders = AED 2,880,000

• 5.46% of the projected gross additional revenue will be spent on employing coders.

• Net increase in revenue = AED 23,728,865 (44.95%)

• Lack of certified coders in the local market

• Sudden demand for coders in Abu Dhabi alone

• Documentation has to be done irrespective of whoever is doing the coding

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ALTERNATIVE III ‐ Outsourcing E & M Coding  

• High costs, on par with ALTERNATIVE II

• Issues with confidentiality of patient information.

• Delay in processing claims.

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2. The Idea (contd.)

Advantages / Disadvantages of various alternatives

ALTERNATIVE IV ‐ E & M Coding by Physicians

Advantages:

• Real‐time coding

• Increased sense of ownership for documentation because “Not documented, not done; not done means will not be paid for”

• Low cost, mainly training cost

• Less number of coders i.e. annual cost of 4 coders = AED 288,000 

• Additional revenue generated would be AED 26,608,865 (50.41% )

• AED 288,000 (0.55%) of the projected gross additional revenue of will be spent on employing coders and AED 30,000 (0.06% )would be spent on training

• Net increase in revenue by AED 26,290,865 (49.80%) i.e. 4.85% more than when coding by coders  13

2. The Idea (contd.)

Disadvantages:

• Modification of documentation methodology; this is required even if the coding is done by the coders. 

Based on the study it was decided that Alternative IV ‐ E & MCoding by Physicians would be a sustainable model.

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2. The Idea (contd.)

3. People Involvement (contd.)

• How was the team formed (cross‐functionality) ?

Interdisciplinary team was formed with representation from:

– Physicians

– Medical records including Medical coders

– Insurance

– Nurses

– Quality department

– Administration

– Human resources

Training team consisted of members from Physicians, medical records & medical coding specialists 

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• How was the stakeholder buy‐in acquired?

– Having trainers from physicians helped us in understanding their perception and to reach out to the physicians.

– The following advantages were discussed:

• Reduction of documentation time

• More time for clinical examination & patient interaction

• Increase in Department revenue

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3. People Involvement (contd.)

• How were the resources / budget determined and obtained for the project?

– Training cost – 20,000 AED

– External Auditing cost – 10,000 AED

TOTAL COST = 30,000 AED

– Annual cost of 4 coders = 288,000 AED

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3. People Involvement (contd.)

4. Process (contd.)

• Explain the process of developing the concept into a detailed plan of a practical solution?

– Study of JCI & HAAD standards, E&M documentation guidelines

– Training on the E & M coding documentation guidelines

– Development of Department specific Assessment forms in collaboration with physicians, medical coders & quality department

– Training on the new assessment forms

– Pilot testing of the forms i.e. 2 forms per physician per department

– Auditing of forms and checking the conformance to documentation guidelines

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• Explain the process of developing the concept into a detailed plan of a practical solution? (continued…)

– Modifying the forms based on the feedback

– Retraining based on the deficiencies that are found during audit of the completed forms

– Deployment of the modified forms for all patient visits

– Auditing of forms and checking the conformance to documentation guidelines

– External audit by 3rd party

– Certification for E&M coding

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4. Process (contd.)

Gantt Chart

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4. Process (contd.)

4. Process (contd.)

• How was the feasibility of the solution evaluated? What tools/techniques were used for analyzing feasibility?

1. Competency of the doctors to code using Competency tests.

2. Internal inventory of talent to design an acceptable, compliant easy‐to‐use form‐ using Talent inventory.

3. Revenue projection‐ Net revenue gain of AED 26,290,865 (49.80%)

4. Opportunity loss of AED 42,861,950 (81.20%)

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4. Process (contd.)

• Was any Risk Assessment carried out (risks involved in the proposed solution itself)?

– Inaccurate coding – risk

– Irrecoverable receivables due to insurance rejection.

– Comparison of Financial risk of proceeding with certification and not proceeding with the same.

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4. Process (contd.)

• How was the Idea (solution) pilot tested for implementation?

• The modified specialty specific forms that were developed were pilot tested i.e. 2 forms per physician per department

• These forms were audited by the coders and the quality department on a daily basis

• Feedback about the forms received from the physicians i.e. spacing, addition, deletion etc.

• Feedback provided to the doctors about the completeness and accuracy of the documentation

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ROLE INNOVATION• Doctors were trained to code the consultation as a part of their 

documentation. Doctors therefore took on the role of the coder thus reducing the need for  separate coders for E&M coding. 

• Thus, a costly layer of coders in the process of finalizing the claim was removed. A significantly lesser number of coders (thin layer) are involved in audits and personal feedback to ensure a sustained level of high accuracy of coding.

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4. Process (contd.)

FORM INNOVATION• Incorporation of E&M coding documentation requirements.

• Improved data capturing by tick marks instead of free hand writing.

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4. Process (contd.)

Old version of forms

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4. Process  (contd.)

New version of forms

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4. Process

4. Process  (contd.)

MISTAKE PROOFING• Comprehensive checklist methodology which gives the doctor a reminder 

to ask relevant questions. 

• Incorporates the coding calculation as a part of the flow of the document capturing, enabling the doctor to score along the way.

What were the results for the pilot trials?– Results showed a coding accuracy of 80.6% during pilot trials.

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4. Process (contd.)

• How was the full scale implementation planned?

– The assessment forms were further modified based on the feedback

– Retraining was done focusing on deficiencies found during the audit of the completed forms

– Deployment of the modified forms for all patient visits from 15th

July,  2011

– A continuous audit of forms was performed to ensure the highest  accuracy

– Target was to obtain a E &M coding accuracy of 90% and overall coding accuracy of 95% by 30 August 2010

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• How were the risks at the various stages of implementationidentified and mitigation planned?

– The  inaccuracies identified were under‐coding, over‐coding and incomplete documentation

– One to one feedback was provided to the physicians

– Assessment forms were further modified with inputs from the physicians to make it user‐friendly

– Coding audit process was started to ensure that the process of coding was correctly complied with and led to highest accuracy of coding (please refer next slide).

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4. Process (contd.)

• How was the implementation monitored and controlled?

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4. Process (contd.)

• How were the various stakeholders informed and their support obtained?

– Training

– Meetings

– Administrative Rounds

– One‐to‐one communication

– Intranet communications

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4. Process (contd.)

5. Results

External audit by 3rd party was completed by 01st Sep 2010

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Planned

• E & M coding Accuracy – 90%

• Overall coding accuracy – 95%

Actual

• E & M coding Accuracy – 91%

• Overall coding accuracy – 97%

What were the actual benefits realized from theimplementation?

– First private sector hospital in Abu Dhabi to complete coding auditsuccessfully.

– Improvement of overall medical documentation

– Lesser time spent for medical documentation.

– Annualized increase in net revenue of AED 26,290,865 (49.8%)

– A saving of salary expenses for additional coders of AED 2592000

– An avoidance of an opportunity loss of AED 42,861,950 (81.2%)

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5. Results (contd.)

What were the actual benefits realized from theimplementation? (contd.)

The benefits support the strategic objectives and mission of the hospital:

1. Increasing net revenue.

2. Decreasing expenses.

3. Increased patient satisfaction.

4. Compliance with regulatory requirement.

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5. Results (contd.)

• List other intangible benefits

– Helped in standardization of documentation

– Enabler for better documentation

– Address the issue of illegibility of doctor’s notes

– Helped in preparation of templates for Electronic medical record

– Replication of the same documentation methodology across 3 hospitals under NMC healthcare 

– Increased efficiency of physicians

– More time for physician‐patient interaction

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5. Results (contd.)

• How was feedback obtained from various stakeholders? Howwere they impacted? What was their perception?

1. Patient satisfaction survey.

2. Feedback from doctors

3. Coding audits by coders

4. Feedback from insurance department.

The overall impact was a positive one. The doctors found the new 

assessment form quite time saving and easier to use. 

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5. Results (contd.)

6. Learning

• What Went Well and What Went Wrong?– What Went Wrong – the date of start of using the E&M coding based rates was postponed.

– What went well – simplification of gathering patient information.

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• Single Point Lesson Learnt?• Innovation of the current medical documentation to

incorporate E&M coding requirements led to regulatorycompliance, better documentation and greatly increasedrevenues.

REPLICATION

• Replication of the same documentation methodologywas implemented across 3 hospitals under NMChealthcare

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6. Learning (contd.)

What would you do differently  the next time you do a similar project?• We would try to implement it in an e‐format right from the 

beginning. 

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6. Learning (contd.)

7. Way Forward

• How were the team members recognized?– Coding accuracy was included as one of the criteria for judging the best department.

– Certificates were distributed to the trainers and best departments.

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• Future development of the idea or using the same idea in different applications– Nursing e‐documentation.

– Quality e‐documentation.

– Infection control e‐documentation.

– Operation theatre e‐documentation.

– Day care e‐documentation.

– Observation e‐documentation.

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7. Way Forward (contd.)

Q & A

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Thank You

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