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Nurse ExecutiveCase Management Workshop
Home Town HealthAnderson Goodwill Conference CenterMacon, Georgia
Prepared by:
Sherry A. Milton, RHIAMilton & Associates, LLCErin, Tennessee 37061
June 22, 2010
Pre-RAC Audits
SHIP HOSPITALS – NON-SHIP HOSPITALS
Sample – 30 Records
October 2007 – Present Focused DRG List
Method of Selection – Selective
Focus RAC audit list Review report utilizing All ICD-9-CM codes assigned Length of Stay Secondary codes assigned Procedures performed (if applicable)
FINDINGS
Total Records: 148 Pre-review CMI – 1.2679 Post-review CMI – 1.3420
Total Changes – 61 Decrease – 17 Increase – 44
Cumulative change/chart - .0741 Total cumulative change – 10.9668 Total Revenue Enhancement - $60,317.75
IMPACT
Recovery Audit Contractor (RAC) Impact 11% of Total number of records reviewed Weight Decrease – 6.3375 Revenue - $34,850.00
Total Impact 41% of Total number of records reviewed Total Weight Change – 17.3043 Revenue Change - $95,200.00
HOSPITAL LIFE TODAY
Deliver high-quality care
Achieve acceptable outcomes
Reduce LOS
Be most cost-effective
Healthcare Environment
More Consumers/Patients are using the Internet to seek healthcare information.
14% of Consumers seek out the cost of treatment options on the Internet.
39% of Consumers look for information that compares treatment options.
72% of Consumers search for treatment information
Baby Boomers approaching Medicare eligible age within the next 6-7 years
MEASURES FOR COMPLIANCE
Regulatory Compliance
Physician Profiles
Hospital Profiles
DRG Assignment
Medicare Severity – MS-DRG’S
FY 2008 CMS will make significant changes to DRG systems to better reflect patient severity of illness.
Allow for better reimbursement accuracy for patients with utilization costs due to higher severity of illness.
Actually looking into what treatment costs to discourage hospitals from hand-picking healthy patients.
(Should even playing field for specialty hospitals.)
Documentation Specialty Program
Develop Case Management/Documentation Specialty Program
Establish Top 10 DRG’s for facility Develop hierarchy for Each DRG Set Query Physicians concurrently Make sure documentation is present before discharge Manage LOS for Transfer DRG’S Compare Coder DRG Assignment with Documentation
Specialty DRG Assignment as an educational tool Monitor Case Mix Index (CMI) as patterns develop
Payment Method
Case Mix Index (CMI) – The sum of all MS-DRG weights divided by the total cases for a given period.
Standard Rate – The average payment for a given geographic area.
Payment – Weight X rate
Example DRG 292 – Heart failure and Shock W CC
.9740 X 5500.00 = $5,357.00
MS-DRG’s LOGIC
Severity Medical and Surgical Same Logic Total 989 MS DRG Triplets
W/O CC/MCC W CC W MCC Constant
Principal DiagnosisSecondary Diagnoses
Principal Diagnosis – The condition after study that is responsible for occasioning the admission to the hospital.
Secondary Diagnosis Clinical evaluation Therapeutic treatment Diagnostic procedure Extended length of hospital stay Increased nursing care and/or monitoring
Severity of IllnessComplication/Co-morbidity
MCC – Major Complication Co-morbidity
Complication – A condition that arises during the hospital stay that extends the length of stay by at least 1 day in 75% of the cases.
Co-morbidity – Pre-existing condition that will extend the length of stay by at least one day in 75% of the cases because it coexists with the principal diagnosis.
MS-DRG Success Physician documentation of pertinent
diagnoses will be key.
Coding professionals will be more instrumental in achieving accurate reimbursement.
Physician query processes will need to be increased and strengthened.
Collaboration between coding and quality measure processes.
Congestive Heart Failure
DRG 291 – Heart Failure and Shock with MCC – Wt. 1.4609
DRG 292 – Heart Failure and Shock with CC – Wt. .9740
DRG 293 – Heart Failure and Shock w/o CC/MCC – Wt. .6940
TODAY’S HOSPITAL ENVIRONMENT
MANAGE IT
PROVE IT
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