Your Compass For Navigating Clinical Documentation: Turbulent Financial Waters for Revenue Cycle 2015 The Foundation for Revenue Cycle Excellence Thomas Sills omas Sills, , MD Founder and President, Clinical Financial Resource, Inc . Che Cheryl Ros Rosa, , RN, BS, CCDS RN, BS, CCDS Director of CDI Operations Project Manager for Lahey Hospital and Medical Center Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 1
Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 Financial Drivers of Clinical Documentation Improvement (CDI) • DRGs • Professional Coding and Billing • OPPS • HCC Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 Financial Drivers of Clinical Documentation Improvement • Pay for Performance – Value Based Purchasing – HACRP – HRRP – PSIs – IQIs – HACs 2
Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 Financial Impact of CDI on Inpatient Revenue Increase CMI from 1.3 to 1.4 at mid-size hospital with blended rate of $6000 and 4000 discharges/year: 0.10 X $6000/discharge X 4000 discharges/yr = $2,400,000 per year Your Compass For Navigating Turbulent Financial Waters for Financial Impact of Clinical Revenue Cycle 2015 Documentation on Medicare Advantage • Increase average RAF (risk adjustment factor) per patient from 1.0 to 1.1 based on documentation. The effect on Health Plan with $600 pmpm payment and 10,000 covered lives: 0.10 X $600 pmpm X 10,000 members = $600,000/month increase 3
Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 Financial Impact of Documentation on Professional Billing • Increase E&M levels from average of 3.5 to 4.1 in Emergency Department with 30,000 visits per year • Equivalent to an increase in 0.81 RVUs per encounter. 0.81 rvu/pt X $35/rvu X 30,000 pts/yr = $850,000/yr Your Compass For Navigating Turbulent Financial Waters for Financial Impact of Documentation Revenue Cycle 2015 on Pay for Performance Measures • Inadequate documentation result in falsely elevated numbers of Patient Safety Indicators (PSIs) and poor risk adjustment of severity of inpatient cases can result in loss of Medicare revenue: – 1% in HACRP – 1.5% in VBP – 3.0% in HRPP For Hospital with $35,000,000 in annual Medicare Revenue, 5.5% of $35M = $1,925,000 is at risk 4
Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 Clinical Documentation Impact on Coding • Documentation determines coding • Coding determines: – Payment – Quality metrics – Resource utilization metrics – Risk adjustment of cases – Pay for Performance – Medical necessity Your Compass For Navigating Turbulent Financial Waters for Coding: Healthcare’s Clinical Revenue Cycle 2015 Accounting System • Every encounter/claim – ICD-9 diagnosis code • Reason for service • Justification for Medical Necessity • Risk adjust encounter/pt • Determines payment – ‘Service Code’ • E&M code • CPT procedure code • ICD-9 procedure Code • Determines Payment 5
Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 Lahey CDI Program • History – 2011 - 0.75 FTE – 2012 – 1.5 FTE – 2013 – 2.0 FTE – 2014 – 3 FTE – 2015 – 5 FTE Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 Targeting of Cases • Small vs. Large CDI staff • Medicine vs. Surgery • Information sources for targeting – Coding/DRG validation – Physician Advisor – Quality – Case management 6
Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 Technology • CDI tracking – Manual – CDIS 3M 360 Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 Communication • Interaction between Departments – CDI – Coding – Quality – Case Management – ACO 7
Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 Physician Engagement • Education and involvement by Physician Advisor • Repetition • Building close relationships Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 Data Collected • Volume • Percentage of Queries • Physician response rate • SOI/ROM • UHC data • CMI 8
Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 CDIP/CDIS Query Financial Impact FY 14 Pre ‐ Query Reimbursement Post ‐ Query Reimbursement Difference $30,000,000 $24,096,456 $25,000,000 $20,000,000 $15,830,769 $15,000,000 $7,930,563 $10,000,000 $7,197,071 $8,265,687 $4,465,738 $4,503,084 $5,102,440 $2,977,653 $4,699,702 $3,050,974 $5,000,000 $2,497,369 $2,828,123 $1,488,085 $1,452,110 $0 Q1 Q2 Q3 Q4 YTD 17 Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 CDIP/CDIS Query Response Rate FY 14 Total Charts Reviewed Total Queries MD Responded No Response % Rate Response 7041 7000 6000 5000 4000 3000 2399 2283 1991 1673 2000 1419 1348 737 700 726 1000 491 488 471 438 371 376 262 249 100 115 79% 77% 66% 63% 70% 0 Q1 Q2 Q3 Q4 YTD 18 9
Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 No Response, MD Queries, September 2014 Pre-Query Post-Query Attending Physician Query Type: Financial I mpact Financial I mpact Service: CARDI OLOGY 003 Clinical Findings $74,058.73 $109,851.39 $35,792.66 COLON RECTAL SURGERY GENERAL I NTERNAL MEDI CI NE HEPATOBI LI ARY SERVI CES HOSPI TALI STS NEUROSURGERY HOSPI TALI STS 041 Pneumonia Specificity $7,813.35 $7,813.35 $0.00 19 Your Compass For Navigating Turbulent Financial Waters for No Response, MD Queries, September 2014 Revenue Cycle 2015 Attending Physician Pre-Query Post-Query Query Type: Financial I mpact Difference Service: Financial I mpact GENERAL I NTERNAL 210 Documentation $60,172.99 $77,055.21 $16,882.22 MEDI CI NE Clarification HOSPI TALI STS ORTHOPAEDI C SURGERY PERI PHERAL/ VASCULAR SURGERY VASCULAR MEDI CI NE HOSPI TALI STS 227 Rule Out Sepsis $8,071.65 $8,071.65 $0.00 20 10
Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 CDIP/CDIS SOI and ROM Increases FY 14 Total Charts Total # Cases w/ SOI Increase Total # Cases w/ ROM Increase Total # Cases w/SOI/ROM Increase 8000 6901 7000 6000 5000 4000 3000 2143 1991 2000 1489 1419 1348 1082 1000 697 554 450 340 319 263 235 206 222 217 207 147 108 0 Q1 Q2 Q3 Q4 YTD 21 Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 22 11
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Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 CMI FY 14, 13, 12 FY 1.7681 12 FY 1.8278 13 1.8401 FY 14 1.6900 1.7100 1.7300 1.7500 1.7700 1.7900 1.8100 1.8300 1.8500 1.8700 1.8900 27 Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 Medical CMI FY 14, 13, 12 FY 1.1739 12 FY 1.2152 13 FY 1.2115 14 1.15 1.16 1.17 1.18 1.19 1.2 1.21 1.22 28 14
Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 Surgical CMI FY 14, 13, 12 FY 2.6949 12 FY 2.8112 13 2.8384 FY 14 2.6 2.65 2.7 2.75 2.8 2.85 29 Your Compass For Navigating Turbulent Financial Waters for Revenue Cycle 2015 CDI PRESENTATION SCHEDULE, FY14 Depar Department tment Depar Department tment Department Hospital Medicine first group Surgical Critical Care Vascular Surgery and MIDLEVELS Gastroenterology Surgical Residents Neurology Residents Radiology/IR Neurosurgery Mid ‐ levels GIM~BUR Cardiothoracic Neuro Mid ‐ levels Surgery Hematology/ Colorectal Oncology Transplant Hospital Medicine second group General Surgery Emergency Medicine Cardiology Gynecology Urology Infectious Disease Neurosurgery Case Management Nephrology Orthopedic Surgery Quality Pulmonary and Orthopedic Mid ‐ Levels Coding Midlevel's Plastic Surgery Admitting 30 15
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