opportunity for education - acdis · make your spreadsheet 4. reverse order from newest to oldest...

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Erica E. Remer, MD, FACEP, CCDSPresident and FounderErica Remer, MD, Inc.

Beachwood, OH

Targeted DRG Reviews to Optimize Documentation, Coding, Metrics, and Reimbursement

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Select DRGs for targeted review

– Identify opportunity by performing targeted reviews

– Create and implement an action plan based on findings

– Improve documentation, quality metrics, and reimbursement in targeted areas

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Why Me?

• Emergency physician for 25 years

• Clinical documentation integrity physician advisor for multihospital system for 4 years

• Consultant in documentation, CDI, and ICD‐10 since July 2016

• I am not an informaticist or analyst

2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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How Did I Settle on This Process?

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What Did I Find?

• Opportunity for improved provider documentation

• Coding opportunity (ICD‐10)

• CDI opportunity

• Compliance opportunity (H&P, APP attestation)

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What Did I Find?

• Opportunity for improved provider documentation

• Coding opportunity (ICD‐10)

• CDI opportunity

• Compliance opportunity (H&P, APP attestation)

Opportunity for Education


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Data Used in This Presentation

• The data is ever evolving, but the numbers don’t change drastically year to year

– Relative weights from CMS MS‐DRG list, version 34; 2016

– DRG distribution from 2015 CMS data set (MedPAR)

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Targeted DRG Review

• What– Analysis of

• Specific diagnosis or procedure

• Specific DRG

• Specific service line

• Why– Identify opportunity

• In coding

• In documentation

– Optimize

• Quality metrics

• CMI, reimbursement

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Which DRGs?

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How to Select a Target

• They come to you for help

– Ranking

– Quality metrics

– $

– Skeptical of CMI

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• New

– Provider

– Service line (e.g., trauma)

– Residency program


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• Recurrent queries for same comorbidities

– Provider problem vs. service line

– Process problem

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• Current practice or literature identifies targets

– DRG shifts

– Clinical validation denials

– OIG targets

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• High yield expected

– High volume

• C‐section without CC/MCC

– High likelihood

• Vasculopaths undergoing extremity bypass

• Deceased without CC/MCC

– High yield

• Surgical DRGs

• High weight differential between no CC/MCC and with CC/MCC


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• Fishing expedition

– Deviation from benchmarks (national, state average, benchmark organizations like Vizient, competitors)

– No CC/MCC (in either two‐ or three‐tier DRG sets)

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What Is Wrong With CMI as Sole Metric?

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No CC/MCC Percentage

[No CC/MCC]

[No CC/MCC + CC + MCC]


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Three‐Tiered DRG

Simple Pneumonia and Pleurisy

193 With MCC 1.3860 41.90%

194 With CC 0.9469 42.61%

195 No CC/MCC 0.7028 15.49%

Respiratory Infections and Inflammations

177 With MCC 1.8672 58.67%

178 With CC 1.3247 33.76%

179 No CC/MCC 0.9325 7.56%

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Two‐Tiered DRG

Viral Meningitis

75 With CC/MCC 1.6970 75.19%

76 No CC/MCC 0.9596 24.81%

Epistaxis

150 With MCC 1.3394 25.51%

151 No MCC 0.7091 74.49%

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Comorbidity Opportunity


Benchmk Your inst.

193 With MCC 1.3860 41.90% 34.72%

194 With CC 0.9469 42.61% 33.92%

195 No CC/MCC 0.7028 15.49% 31.36%


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Benchmk Your inst.

193 With MCC 1.3860 41.90% 34.72%

194 With CC 0.9469 42.61% 33.92%

195 No CC/MCC 0.7028 15.49% 31.36%

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Benchmk Your inst.

193 With MCC 1.3860 41.90% 34.72%

194 With CC 0.9469 42.61% 33.92%

195 No CC/MCC 0.7028 15.49% 31.36%

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Benchmk Your inst.

193 With MCC 1.3860 41.90% 34.72%

194 With CC 0.9469 42.61% 33.92%

195 No CC/MCC 0.7028 15.49% 31.36%

31.36 – 15.49 = 16.47


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Benchmk Your inst.

193 With MCC 1.3860 41.90% 34.72%

194 With CC 0.9469 42.61% 33.92%

195 No CC/MCC 0.7028 15.49% 31.36%

31.36 – 15.49 = 16.47

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Benchmarking and Results

• Premises:

– Looking for educational opportunity

– Lessons learned from one DRG set are transferrable to other DRG sets

– Aggregate benchmarks are suspect

– [No CC/MCC] will never reach zero

– Prior time period will give an approximate baseline for your organization, but CMI is multifactorial

– Shifts not guaranteed to stay in the same DRG set

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Targeted DRG Review

• Process

• Reports

• What to do with findings


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Step 1

1. Select your targeted DRG(s)

– How many charts to review? (All or a subset?)

– No CC/MCC (most productive review)

Why not CC MCC review?

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Step 2


2. Run a report with:– Patient and provider identifiers

– Dates of service

– Calculate actual LOS

– Current DRG (MS? APR?)

– Relative weight

– ALOS

– SOI

– ROM

– $

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Step 3


2. Run a report

3. Make a spreadsheet by adding to report:– Post review numbers: DRG2; RW2; ALOS2; SOI2;

ROM2; $2– Pre review – post review change = ∆ RW; ∆ ALOS; ∆

SOI; ∆ ROM; ∆ $

– CDI review (Y/N; initials of CDIS; opportunity; no response from HCP?)

– Your findings of opportunities (columns for common ones; categories; notes for feedback)


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Step 4


2. Run your report

3. Make a spreadsheet

4. Reverse order from newest to oldest

– What is your rebilling window?

– What is your time threshold for retrospective queries?

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Step 5


2. Run your report

3. Make your spreadsheet


5. If volume mandates selection, look at encounters where the actual LOS exceeds the ALOS (by a number of days; by a percentage?). Sort by longest LOS to shortest.

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Step 6


2. Run your report

3. Make your spreadsheet


5. Encounters where the actual LOS exceeds the ALOS, longest first

6. Review MR– Refer to coding abstract

– Previous encounters

– Labs/reports/consults, etc.


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What Are You Looking For?

• In the right DRG? Right principal diagnosis, right principal procedure?

• Are there CC/MCCs that were documented, but not coded?

• Are there conditions intimated, but not documented adequately for coding?

– CC/MCC/HCCs

– Did a CDIS review it concurrently and catch them?

• Are all ICD‐10‐PCS procedures captured?

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• Note all opportunities, even if they don’t impact the metrics (you may catch patterns or trends; feedback on documentation for HCPs)

• PSI/HAC, medical necessity, quality issues?

• Are there any compliance issues? (e.g., critical care billed, but inadequate documentation; no preoperative H&P in the encounter)

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Demographics

Pt name

MRN MD Date adm

Date d/c’d

Actual LOS

Doe, John

123456789 ER 1/3/16 1/12/16 [= d/c – adm date]


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DRG Numbers

MS DRG MS RW MS ALOS SOI ROM $

267 6.472 4.4 4 2 $48,540

(Endovascular Cardiac Valve Replacement without MCC)

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CDI Review

CDIS Y/N CDIS Query Notes

Y JR Y Queried HF; no response

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DRG Numbers2

MS DRG2 MS RW2 MS ALOS2 SOI2 ROM2 $2266 8.3933 8.5 4 3 $62,950

(Endovascular Cardiac Valve Replacement with MCC)


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in DRG Numbers

MS RW MS ALOS SOI ROM $

1.9213 4.1 0 1 $14,410

Consistent calculation – base rate; encoder output

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Opportunity Findings

Coding opp

Coding opp note

Doc opp

Ac HF

Ac resp fail

Enceph Documentation opportunity note

3 NA Y 1 0 0 “with ADHF,” EF 32%; BNP 8145; “fluid overloaded,” diuresis of 2 L, “symptomatic improvement”

Y w/ = 1Y wo/ = 2N = 3

Columns for the most common conditions for that DRG

Y = 1, N = 0Can tally

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• Sort findings by:

– Actual recouped $/improved metrics (coding opportunities)

– Queries generated – if agreed recouped $/ improved metrics (provider documentation opportunities)

– Queries indicated but not done concurrently (CDIS opportunities)

– Potential recouped $/improved metrics

• Likely vs. difficult to tell


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Reporting

• The administration/provider leader will want numbers and findings in a digestible format

– Spreadsheet

– Report

– Action items

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Educational Opportunities

• Feedback to coders, CDISs, HCPs

• Sum up findings for more general dissemination

– Educational presentations

– Email blasts

– Tip cards

– CDI tips

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Ongoing Reviews

• Identify DRGs that warrant ongoing second‐level review

• Continued feedback and repeat education as needed


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Permanent Impact

Impossible to exactly quantify

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Benchmk CO1 CO2

193 With MCC 41.90% 34.72% 37.88%

194 With CC 42.61% 33.92% 39.84%

195 No CC/MCC 15.49% 31.36% 22.28%

31.36 – 15.49 = 15.87

22.28 – 15.49 = 6.79

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BenchmkYour

BenchmkCO2

193 With MCC 41.90% 39.34% 37.88%

194 With CC 42.61% 42.01% 39.84%

195 No CC/MCC 15.49% 18.65% 22.28%

22.28 – 18.65 = 3.63


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No CC/MCC CC MCC

CC/MCC Distribution

Benchmark 1st Review True Benchmark 2nd Review

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Examples of Findings

• Neurosurgery– DRG 27

• Not homogeneous; adult, brain excisions with significant opportunity

• Coding accuracy was 97%• 27.4% with 1 or more opportunities (26/95)

• 22/36 of opportunities were for cerebral edema and/or brain compression

• CMI would have gone from 2.2826 to 2.7662 with additional revenue of > $200,000; actually recouped ~$40,000

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• Neurosurgery– DRG 27

• Need preoperative H&P in THIS encounter• Review and capture diagnoses from imaging that elicited the surgery

• Encephalopathy• Acute respiratory failure• Seizure DISORDER• Pathology• Malnutrition


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• CORS

– Looked at 331, 334, 346 [CORS cases with no CC/MCC] for 6 months

• As approach ALOS = actual LOS, less opportunity

• Coding accuracy was 92.2%

• 41.2% with 1 or more opportunities (24/51)

• CMI would have gone from 1.6131 to 2.2353 with additional revenue of almost $200,000; actually recouped > $55,000

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• CORS– Lower‐acuity community hospitals with less opportunity

– Missing chronic illnesses found in preop workup but not brought into current encounter

– Vascular disorders not documented in a codable format [“dead, nonviable, dusky” without “ischemia” or “gangrene”]

– ABLA

– AKI/CKD

– Pathology results (especially lymph node mets)

– Malnutrition

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Obstetrics


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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Select DRGs for targeted review

– Identify opportunity by performing targeted reviews

– Create and implement an action plan based on findings

– Improve documentation, quality metrics, and reimbursement in targeted areas

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Thank you. Questions?

[email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.


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opportunity for education - acdis · make your spreadsheet 4. reverse order from newest to oldest...

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