June, 2016
Patsy Raworth, RHIA
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AGENDA:
 History of Program
 New Box
 Results
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1994 DRG Review
- external Physician Advisors
1996 Begin training internal Physician
Advisors
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DRG Coordinators and Utilization Review
o Collaborative Effort
o Reorganized Department
o Case Management, UR, Quality and HIM
o
Dollar Storm
o Length of Stay
o CMI
o DRG Review
1.8
1.6
1.4
Physician Advisors Combined efforts of DRG
EPF Implementation
begin (3/96)
Coordinators and Utilization
Review
HCFA Rel Wt
Adjustments
October
Clinical
CDI
1.2
1
Huff begins
(3/95)
Merged QR, Social Work
ARMS
MBMC Case Mix Index 7/94 - present
All Financial Classes
0.6
0.4
HCFA Relative Weight
Adjustments (October)
EPF Implementation
0
HDM
DRG Coordinators took on the
role of Quality Abstracting
(10/01)
0.8
0.2
SMART
MS-DRG
 DRG Assurance
 Physician Engagement: Identifying Documentation
Improvement Opportunities
Determine parameters for Benchmark (Facilities, Benchmarking parameters for Cohort comparisons)
Pull Benchmark reports for member and benchmark data (MS-DRG Group Opportunities & Code Level Opportunities)
Save reports in tool
Identify variances in CC/MCC capture rate & select high priority DRG's
Vet Secondary Dx that Cohort is utilizing
Perform chart review (if necessary)
Have conversations with clinical staff around Secondary Dx gaps
Record and summarize results
Create education collateral (tip sheets, presentations, etc.)
Track results
Capture Underpayment Opportunities
Save reports in tool
Select high priority Risk Targets for deeper examination & risk mitigation efforts
Use CDI and coding knowledge to determine extent of actual risk
Perform chart review (if necessary)
Update (or create) queries and institutional processes based on data
Create education collateral (tip sheets, presentations, etc.)
Work with key physicians to ensure thorough documentation
Track results
o Steering Committee
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o
o
o
o
o
o
Physician Advisor - only focus
Chief Executive Officer
Chief Medical Officer
Chief Financial Officer
Chief Operating Officer
Executive Director of Revenue Cycle
HIM Director
o Monthly Meetings
o Benchmarks
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9-1-2015 Rounding
◦ Specific Specialties
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Critical Care
Cardiology
Hospitalists
Family Medicine
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With rounding charts will need to be updated
daily.
◦ Admission – discharge or transfer
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Discuss the case with the physician.
If you don’t know what something is – find out!
Be prepared
IT IS NOT ABOUT YOU or YOUR DECISIONS.
This is your world –not theirs. You are the expert
AND the educator.
Defensiveness weakens your position
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The Process
◦ CC/MCC Capture
◦ Query Process
◦ CMI
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CC/MCC Capture rate
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Physician Response rate
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Unspecified Code usage
1.85
1.8
MBMC Dollar Storm Case Mix
1.75
1.7
1.65
1.6
1.55
1.5
1.45
1.4
MBMC CMI
MCC/CC Capture Rate
100
90
80
70
60
Surgical Capture Rate
Surgical Capture Goal
50
Medical Capture Rate
Medical Capture Goal
40
30
20
10
0
Dec-14Jan-15Feb-15Mar-15Apr-15May-15Jun-15Jul-15Aug-15
Sep-15Oct-15Nov-15
Dec-15Jan-16Feb-16Mar-16Apr-16May-16
Query MD
Title Pts w/Query
# MD Queries # Withdrawn
# MD Responses # MD No Response % MD Response Rate
A
7
9
2
4
3
57
B
4
9
0
5
4
56
C
9
14
1
7
6
54
D
3
5
1
2
2
50
E
2
4
0
2
2
50
F
4
4
0
2
2
50
G
9
14
1
5
8
38
H
5
7
0
2
5
29
I
3
5
0
1
4
20
J
9
11
0
1
10
9
Mississippi Baptist Health System – Unspecified Code Usage
Unspecified Code Usage across
Project Details
• The last three months are
showing a slight increase in
unspecified code usage.
• Methodology includes
identifying top specialties with
unspecified code usage to focus
educational efforts.
Six Month Trend – All MBHS
26.00%
24.00%
– CMI improvement across
transition:
• All Payer:
22.00%
– Nov ‘15: 1.70
– Dec ‘15: 1.77
– Jan ‘16: 1.78
20.00%
November
– Feb ‘16: 1.72
– Apr ‘16: 1.68
– Pediatrics as a whole saw a
large improvement this month
dropping almost 9% from
March to April.
– Pediatric Gastro continued a
small upward trend.
January
February
March
April
Specialties with Highest Unspecified Code usage in Oct-Dec 2015
(compared against Jan-Apr 2016)
– Mar ‘16: 1.77
• Specialty Level Observations
December
Date Comparison
Pediatric Gastro
Pediatrics
Jan - Apr
Oct - Dec
Acute Care
Emergency
Medicine
Family Medicine
0.0%
10.0%
20.0%
30.0%
40.0%
1 – IP Claims only
2 – Specialties with at least 100 claims each month
Unspecified Code Usage – Hospitalist Drill Down1
Specialty Highlight:
Hospitalists
30.00%
25.00%
20.00%
15.00%
MBHS
Cohort
Apr-16
Mar-16
Feb-16
Jan-16
Dec-15
Nov-15
Oct-15
Sep-15
Aug-15
Jul-15
Jun-15
May-15
Apr-15
Mar-15
Feb-15
Jan-15
Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
10.00%
May-14
• While both the
organization and
hospitalists are
maintaining an
unspecified code
usage rate lower than
the cohort,
Hospitalists are
seeing a larger
uptick.
35.00%
Apr-14
• The decline in
unspecified code
usage in October is
consistent with the
cohort.
Hospitalists Compared to MBHS Average1
Mar-14
• This chart represents
the percentage of all
unspecified codes
used (PDx, SDx, or
Px).
Hospitalists
1 – IP Claims discharged 10/13-9/14 and 10/14-9/15
Unspecified Code Usage – Hospitalist Drill Down (continued)
ICD-10 Transition Comparison
50%
45%
Feb
40%
Mar
35%
30%
Apr
25%
MBHS Avg (Apr)
20%
15%
Spec. Avg (Apr)
10%
5%
0%
Individual Physician Performance
March Top Unspecified PDx Codes Used1
April Top Unspecified PDx Codes Used1
Sepsis, unspecified organism
Sepsis, unspecified organism
27
23
Gastrointestinal hemorrhage, unspecified
Acute kidney failure, unspecified
12
82
8
11
Unspecified bacterial pneumonia
71
Noninfective gastroenteritis and colitis,
9
Pneumonia, unspecified organism
8
Other individual codes (53)
Unspecified bacterial pneumonia
9
9
unspecified
Acute kidney failure, unspecified
Other individual codes (53)
1 – IP Claims only
Unspecified Code Usage – Cardiology Drill Down
ICD-10 Transition Comparison
35%
Feb
30%
Mar
25%
20%
Apr
15%
10%
MBHS Avg (Apr)
5%
Spec. Avg (Apr)
0%
BELLAN
BENSLER
FIGUEROA
FYKE
HARPER
LAWSON
REYNOLDS
Individual Physician Performance
March Top Unspecified PDx Codes Used1
THORNE
1
WATERER
April Top Unspecified PDx Codes Used1
1
1
WARNOCK
ST elevation (STEMI) myocardial infarction of unspecified site
Hypertensive heart and chronic kidney disease with heart
2
failure
ST elevation (STEMI) myocardial infarction of unspecified
site
Cardiac arrest, cause unspecified
3
1
1
Atherosclerotic heart disease of native coronary artery
with unspecified angina pectoris
Nausea with vomiting, unspecified
Unspecified atrial fibrillation
1 – IP Claims discharged 10/13-9/14 and 10/14-9/15
Unspecified Code Usage – Pulmonology Drill Down
30%
25%
Feb
20%
Mar
15%
Apr
MBHS Avg (Apr)
10%
Spec. Avg (Apr)
5%
0%
Individual PhysicianRappai
Performance
McGee
March Top Unspecified PDx Codes Used1
April Top Unspecified PDx Codes Used1
Pneumonia, unspecified organism
7
Sepsis, unspecified organism
13
2
Sepsis, unspecified organism
3
6
Bacterial meningitis, unspecified
2
Unspecified asthma with (acute) exacerbation
Gram-negative sepsis, unspecified
Unspecified bacterial pneumonia
Streptococcal sepsis, unspecified
4
Cannon
5
Other individual codes
2
2
Pneumonia, unspecified organism
2
Other individual codes
1 – IP Claims for November
CMI Trend1
MBHS CMI vs Cohort
1.90
1.80
1.70
1.60
1.50
1.40
1.30
1.20
1.10
MBHS
May-16
Apr-16
Mar-16
Feb-16
Jan-16
Dec-15
Nov-15
Oct-15
Sep-15
Aug-15
Jul-15
Jun-15
May-15
Apr-15
Mar-15
Feb-15
Jan-15
Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
May-14
Apr-14
1.00
Cohort
1 – Cohort includes 350-500+ Acute Care Hospitals in the
South/Southeast region
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Query providers for Severity and Acuity
Develop or engage a 3rd party in providing
education on APR-DRG’s and Risk Adjustment
Implement the APR-DRG as part of the Coding
and CDI processes to prepare for Pay for
Performance and risk-adjusted payment
methods.
Create reports for physician audiences that are
sensitized to patient acuity, SOI/ROM and
Clinical Outcomes.
Train physicians in APR-DRG methodology and
documentation for risk-adjustments
APR-DRG
1.4300
1.4200
1.4100
1.4000
1.3900
1.3800
APR-DRG
1.3700
1.3600
1.3500
1.3400
1.3300
1.3200
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
Methodology:
Oct ’15 – Dec ‘15
All Physicians
System Comparison
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Learning from “One of their Own” Physicians Enhance Documentation Efforts
Challenge: Complications of care
is both a reflection of physician
practice and documentation. The
connection that exists between
these two important indicators is
not always clear to physicians
and can be a challenging area to
inflect positive change.
Solution: MBHS took a twopronged approach to reducing
complications of care. Starting
with physician education, they
began using the complications
of care metric as part of their
monthly evaluation of practice
patterns. We hired a credentialed
physician to serve as a
documentation advisor
connecting the coders and the
doctors.
Impact: *Using a $60 per .01
increase in CMI, enhanced
documentation resulted in
$1,602,000 potential increased
reimbursement in Q4 2015
(5340 cases).
Impact Highlights
$1.6M*
Potential reimbursement
impact from increased CMI
-0.15%
Reduction in Complications of
Care
Leverage Product to assist in education and reports
• Utilize Physician analytical tool and Revenue Cycle
optimization application in collaboration for tools,
benchmarks and measure of success.
• Develop APR-DRG report and incorporate into CFO
dashboard
• Educate Physician Advisor and CDI team lead in
APR-DRG
• Cascade education to Physicians and CDI staff
• Develop new tools and reports for physician
engagement
•
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Maximize Revenue:
Improve CMI and CC/MCC Capture Rate
• Identify secondary codes and physicians within service lines and DRG groups to target
 Pinpointing: 329-331, 219-221, 981-983, 469-470
• Educate physicians and coders based on trends and monitor improvement
Improve Documentation Accuracy:
Reduce Unspecified Code Utilization
• Identify opportunities for improved specificity within service lines, physicians, and codes
 Pinpointing: Surgery, Pulmonology, Orthopedic Surgery, Cardiovascular Surgery
Improve Efficiencies:
Manage audit workflow and improve processes
• Identify required reporting fields through data exception reports in ROC
• Monitor reports for data irregularities
• Organize internal meetings to discuss opportunities for consistent data entry