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