Managing revenue cycles has become increasingly important with healthcare reform’s emphasis on value and efficiency. Analytics help medical systems know where they stand and how they can improve.
Two years ago, executives at the University of Mississippi Medical Center in Jackson began to focus on new reimbursement methodologies. They understood traditional revenue cycle metrics such as days in accounts receivable and coding data.
However, they knew that since the passage of the Patient Protection and Affordable Care Act (ACA) in 2010, there was more of an emphasis on pay for performance and outcomes. The Centers for Medicare & Medicaid Services (CMS) and other payers were basing reimbursement on the quality of care hospitals delivered and holding hospitals accountable for keeping patients healthy and penalizing them for readmissions.
Today, the medical center has adopted initiatives to adapt to the changing landscape, including its Clinical Documentation Excellence program that was launched in 2013. At the time, the director of revenue cycle and health information management, Leigh Williams, and other leaders were learning about CMS programs such as hospital value-based purchasing and readmissions reductions and educating anyone responsible for hospital chart documentation.
“The real challenge was how you transition that into some actionable items and tasks for clinicians to do to drive those outcomes,” says Williams, who now works at the University of Virginia. “How do you help, for example, orthopedic surgeons understand how the hospital readmissions reductions program may be impacting how their quality is viewed and what they’re getting for reimbursement? We had a lot of ‘aha’ moments where you figure out which service lines are heavily impacting which initiatives.”
The goals of the Clinical Documentation Excellence program are to support accurate, timely and complete documentation to help the center communicate with CMS and ensure it receives proper reimbursement. It also helps revenue cycle managers understand where they are competent and deficient and which initiatives to prioritize.
Better metrics, better money
Since the program went into effect, the cardiology practice has seen a 7 percent increase in its case-mix index, a hospital-based reimbursement metric which CMS uses to identify the average diagnosis-related group (DRG) relative weight for hospitals. The increase had led to an improvement in accurate diagnoses and cardiology-based reimbursement. The index also is used in quality measurements.
“Cardiologists were doing a good job with their documentation around the specialty they worked in,” Williams says. “They were good with their cardiology documentation. But we needed to work with them on capturing that full picture of the patient, getting the chronic diseases and other information about the patient that adds those complexities. That then puts them in a different DRG, and it gives it a higher weight.”
The medical center has seen improvements in heart failure diagnoses, as well. Williams and others implemented an initiative across the departments to educate providers on the importance of more specific diagnoses, particularly with ICD-10, which eliminates numerous unspecified codes.
Between September 2014 and March 2015, the Mississippi center reduced unspecified heart failure diagnoses by 78 percent.
“Getting them to more completely describe the condition the patient is in is helpful throughout all of the patients’ care,” Williams says. “The other providers that may be involved in their healthcare can get better, more clear and accurate information about what’s wrong with the patient.”
Clinicians continue to write operative reports and discharge summaries as usual, but they receive help on workflow adjustments for using EHRs and other initiatives. Executives also have designed and developed structured templates that remind and enable clinicians to write and document everything they do and appropriately complete the terminology.
“We have some workflow tools in our EHR that are real-time support for the clinicians to be able to remember and clearly document all of the admissions that they’re seeing,” Williams says.
The medical center's coding group then takes the documentation and provides data on DRG and Current Procedural Technology billing. Employees responsible for revenue cycle management analyze the claims data, which CMS uses for reimbursement.
“It’s not so much having doctors do anything outside