Kim Murphy Abdouch, MPH, RHIA, FACHE

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MANAGEMENT TRENDS IN CODING TxHIMA Annual
Convention June 23, 2008

• Presented by
• Kim Murphy Abdouch, MPH, RHIA, FACHE
• Vice President and Principal MPA Consulting, Inc.

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CC/MCC
DNFB
ICD-10
RAC
MS-DRG
HAC
POA
Never Events
V24/V25
Productivity
CMS
OIG
CMI
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The 2008 coding environment is extraordinarily
complex

• MS-DRGs
• CCs/MCCs
• V24/V25
• CCA
• CCS
• CCS-P
• CPC
• CMI
• ICD-10

• CMS
• DNFB
• OIG
• RACs
• HACs
• POA
• Never Events
• Productivity
• Quality

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Managing effectively in this extraordinarily
changing environment

• Assess your facilitys environment
• Identify the issues
• Create a dashboard
• Prioritize the issues
• Establish an action plan
• Get going!

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MS-DRGs

• The biggest thing since DRGs!
• Is the attitude at your facility ho-hum or does
  your organization recognize the impact?
• Have your physicians been educated about the
  changes in Comorbidities and Complicating
  Conditions?
• Have your coders been educated about MS-DRGs and
  the new CCs and MCCs?

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MS-DRGs

• Do you know who your MS-DRG payers are?
• Do you know which of your payers are still paying
  under the old DRGs?
• Is your encoder set up for the right grouper for
  the right payer?
• Some believe that you can cross walk V24 and
  V25 and be paid correctly
• This is not the case!

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MS-DRGs

• Be sure your contract and in house coders are
  familiar with MS-DRGs and the new CCs/MCCs
• Know which DRG Version each payer is using
• Ensure that your encoder and HIS are set up
  properly so the coders see the correct DRG
  version for each payer
• Ensure that your managed care team has NOT agreed
  to a cross-walk

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MS-DRGs

• Do you have up to date data on your performance
  under MS-DRGs?
• What is your CC/MCC capture rate?
• Under DRGs 77.6 of patients had a CC
• Under MS-DRGs Medicare expects that only 41.2
  will be with CC/MCC
• Are you evaluating your triplicate MS-DRGs as
  you did your paired DRGs?

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RATE YOURSELF ON MS-DRGs
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POA/HACs/Never Events Definitions

• Present on Admission (POA) Conditions that are
  present at the time the order to admit a patient
  to the hospital occurs
• Hospital Acquired Conditions (HACs) Conditions
  that CMS considers to be avoidable if they occur
  after the point of an inpatient admission
• Never Events The National Quality Forum has
  identified 28 serious reportable or adverse
  event conditions that should be reduced or
  prevented

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POA/HACs/Never Events

• CMS is working with NQF and has identified Never
  Events that should be considered Hospital
  Acquired Conditions (HACs) under the POA program
• For discharges on or after October 1, 2008
  hospitals may not receive additional MS-DRG
  payment for cases in which one of the Never
  Event conditions was not Present on Admission
  (POA)

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Present on Admission Indicators

• Y Yes (this diagnosis is present at the time of
  inpatient admission)
• N No (not present at time of inpatient
  admission)
• U Unknown (there is insufficient documentation
  to determine if the condition was POA)
• W Clinically undetermined (provider is unable
  to clinically determine whether condition was
  POA)
• E - Exempt

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POA and Never Events

• POA and Never Event Reporting is expected to
  require additional coding and quality labor to
  document, review, record and report HACs
• Ensure that your coders are trained in POA and
  knowledgeable of the specific Never Event codes
• Establish baseline measures of the distribution
  of the five POA indicators

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POA and Never Events

• Analyze your facility data to determine if there
  are any Never Event codes with a POA indicator
  of N (not present on admission) U (unknown)- W
  (clinically undetermined)
• Investigate patterns of N, U or W
• Establish a flag in the encoder that alerts the
  coders when a Never Event code is assigned
• Establish an internal coding and/or quality
  review of any discharge coded with a Never Event
  code that was not POA

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POA and Never Events

• Establish a query process to obtain clarification
  regarding POA if needed to assign a reason code
• Note Medicares MedLearn Matters 5499 states
  that Issues related to inconsistent, missing,
  conflicting or unclear documentation must still
  be resolved by the provider.

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RATE YOURSELF ON POA AND NEVER EVENTS
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Case Mix Index (CMI)

• Do you know your current CMI?
• Do you track it monthly?
• Is it going up under MS-DRGs?
• Medicare expected us to improve coding and
  clinical documentation and took a 0.6 reduction
  this year (and next) to make up for it
• If your CMI is not going up, you will fall behind
  in reimbursement!

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RATE YOURSELF ON CMI
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Clinical Documentation Improvement (CDI)

• Do you have a CDI program in place?
• Is it concurrent or retrospective?
• Do you have an AHIMA-compliant query process in
  place?
• Do you track CDI results?
• What is the response rate from your medical
  staff?

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CDI Best Practice

• Concurrent queries
• Marriage of HIM/Coding and Case Management
• Concurrent documentation by physicians
• Performance monitoring of queries, responses and
  financial impact

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RATE YOURSELF ON CDI
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DNFB

• Has been viewed as the only HIM function key to
  Revenue Cycle
• Timeliness and accuracy are of significance
• Monitored by of cases and by patient type
• Best practice DNFB is less than 2 days beyond
  bill hold

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DNFB

• All elements contributing to delays in coding
  discharged patient records must be identified and
  addressed number and productivity of coders
  incomplete and delinquent physician
  documentation case management clarification
  requirements inaccurate MPI data, etc.

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RATE YOURSELF ON DNFB
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Coder Recruitment and Certification

• Do you have coding vacancies?
• Do you have a plan in place for recruitment and
  retention?
• Are your coders certified?
• RHIA
• RHIT
• CCA
• CCS
• CCS-P
• CPC

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Coder Recruitment and Certification

• Is Coding Clinic available to your coders on line
  or in hard copy?
• Are continuing education programs available to
  your coders on site and off-site?
• Is non-productive time allocated to support
  continuing education?
• Does the facility reimburse expenses
  certification?

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Coder Recruitment and Certification

• Do you use contract coders?
• Are they certified?
• Is their continuing education up to date?
• Are they oriented to your facilitys coding
  policies and procedures?

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RATE YOURSELF ON CODING RECRUITMENT AND
CERTIFICATION
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Coding Staffing and Productivity

• Coding staffing should be established based upon
  
• patient volumes by patient type
• expected productivity by patient type
• It has been predicted that productivity would
  decrease by 20 under MS-DRGs and POA
• Are you monitoring and reporting your coder
  productivity?

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Coding Staffing and Productivity

• Monitor and address problems in other functions
  that can impact coding productivity
• Transcription turnaround time
• The order and completeness of the record
• The availability of the record
• The legibility of the record
• The availability and sophistication of software
  tools
• Other duties

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Coding Staffing and Productivity
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RATE YOUR CODING STAFFING AND PRODUCTIVITY
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Coding Accuracy

• Are standards for accuracy in place and
  communicated to the coders?
• Is the accuracy of each coder monitored on a
  regular basis?
• Do you routinely/periodically monitor contract
  coder accuracy?
• Does your contractor also monitor and report
  coding accuracy?

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Coding Accuracy

• The OIG recommends regular, periodic compliance
  audits by auditors who have expertise in
  Federal and State health care program
  requirements
• Recommend at least annual revenue integrity
  audits that address the adequacy of clinical
  documentation, coding accuracy, flow of charges
  to the bill and accuracy of the remittance from
  the payer

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Coding Accuracy

• Are there internal and external audits at least
  annually?
• Accuracy rates should exceed 95 at the DRG and
  APC level

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RATE YOURSELF ON CODING ACCURACY
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You can manage effectively in this changing
environment

• Create a dashboard
• Prioritize the issues
• Establish an action plan
• Get going!

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QUESTIONS ?

• For further information please do not hesitate
  to contact me
• Kim Murphy-Abdouch
• [phone]
• kmurphy_at_mpa-consulting.com
• THANK YOU!!