STRATEGIES FOR ENHANCING CLINICAL DOCUMENTATION & PROCESSES TO OPTIMIZE REIMBURSEMENT Northeast Ohio HFMA Physician Summit Series October 24, 2017 Christina Janus, MBA, RHIA Director, Health Information Management, The MetroHealth System Jaclyn Woolnough, CPMA, CRCR Director, Revenue Integrity, The MetroHealth System The following report is proprietary information and constitutes trade secrets of The MetroHealth System and may not be disclosed in whole or part to any external parties without the express consent of The MetroHealth System. This document is intended to be used internally for MetroHealth System discussion.
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STRATEGIES FOR ENHANCING CLINICAL DOCUMENTATION ......Today’s Objectives • Discuss how clinicians, the revenue cycle and information technology collaborate to improve workflow
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STRATEGIES FOR ENHANCING
CLINICAL DOCUMENTATION & PROCESSES
TO OPTIMIZE REIMBURSEMENT
Northeast Ohio HFMA Physician Summit Series
October 24, 2017
Christina Janus, MBA, RHIA
Director, Health Information Management, The MetroHealth System
Jaclyn Woolnough, CPMA, CRCR
Director, Revenue Integrity, The MetroHealth System
The following report is proprietary information and constitutes trade secrets of The MetroHealth System and may
not be disclosed in whole or part to any external parties without the express consent of The MetroHealth System.
This document is intended to be used internally for MetroHealth System discussion.
Today’s Objectives
• Discuss how clinicians, the revenue cycle and information
technology collaborate to improve workflow and clinical
documentation to optimize reimbursement
• Outline the importance of maintaining higher levels of clinical
documentation specificity & accuracy for improved value and
to mitigate risks
• Discuss the importance of Revenue Integrity, areas to target
and considerations for a Population Health World
• Explore best practices on how the use of revenue cycle
metrics, clinical data, and ongoing education to improve
productivity, financial performance and clinical outcomes
Why is the quality and timeliness of provider
medical record documentation important?
• Continuity of patient care & official business record
• Tells a patient’s story
• Documentation of healthcare services provided
• Proves standards of care are being followed as required by governing bodies
• Medical necessity
• Supports what was done and why:
– Patient’s clinical presentation
– Past and current medical history
– Laboratory and other diagnostic studies
– Medications
– Response to treatment
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Why is the quality and timeliness of provider
documentation important?
• Medical coding and billing accuracy
• The diagnostic and procedural codes assigned are based on what the record state
• Payment for services rendered are based on codes provided for billing
• Not Documented = NOT DONE!
• Documentation audits and reviews
• Random vs. Focused
• Compliance vs. Coding vs. Billing
• Internal vs. External
• Legal ramifications
• Prove what care was provided
• Support rational for actions taken or decisions not to take additional action
• Serves as the provider’s memory
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INPATIENT CLINICAL DOCUMENTATION &
REIMBURSEMENT
What is CDI?
• CDI = Clinical Documentation Improvement
• The goal CDI is for complete and accurate documentation of
diagnosis and procedures in the medical record to reflect:
• The patient’s true Severity of Illness
• The patient’s Risk of Mortality
• Accurate Physician & Hospital Quality Profiles
• Optimize the CMI (Case Mix Index)
CMS MS-DRG System
• Relative Weight (wt): Each MS-DRG is assigned a relative weight. This weight
reflects the expected resource consumption and severity of diagnoses within the
MS-DRG and is constant from hospital to hospital.
• Blended Rate: Each hospital is assigned a “blended rate” based on a formula
that includes location, services provided etc. The blended rate varies from
hospital to hospital.
• Reimbursement: Reimbursement is calculated by multiplying the relative weight
by the blended rate.
– Example: Relative weight 0.6618 x blended rate of $4,500 = $2,978.10 reimbursement.
What Determines the MS-DRG?
The MS-DRG is determined by:
• Principle Diagnosis: The condition established after study to be chiefly responsible
for occasioning the admission. Must be Present On Admission (POA) and meet
admission criteria.
• Procedures Performed during the hospitalization
• Complications: A condition that arises during the hospital stay which prolongs the
length of stay. It does not necessarily represent an error in medical care.
• Comorbidities: Pre-existing condition, may be POA, but not the reason for admission.
• Patient age and gender
• Discharge Disposition
Case Mix Index (CMI)
Case Mix Index: The average of all the relative weights of all the MS-DRGs in
a patient population in a given time period.
Example:
CMI Formula: Add all the relative weights and divide by 5.
CMI for this Population is: 2.06506
Description MS-DRG Relative
Weight
1. Heart Failure w/CC 292 0.9707
2. Cholecystectomy w/CC 415 2.0071
3. Sepsis w/ Mechanical Ventilator for
96+ hours
870 5.8782
4. Chest Pain 313 0.6621
5. TURP (Transurethral resection of the
prostate) w/o cc/mcc
714 0.8072
Complication/Comorbidity (CC)
Major Complication/Comorbidity (MCC)
Medicare has designated a number of diagnoses as reimbursable CCs and