In the Midst of Change: How Do We Ensure Revenue Integrity ?

1. In the Midst of Change: How Do We Ensure Revenue Integrity? Sonia Trepina Director, Revenue & Documentation Integrity & Marie Thomas Manager, Documentation Integrity

2. Health System Facts Annual operating revenues, Duke University Health System: $2.35 billion Medical Center campus size: 96 buildings located on 201 acres Gross square feet: 6 million One Academic Medical Center 924 licensed acute care beds 19 psychiatry beds Two Community Hospitals Durham Regional – 369 licensed acute and specialty care beds Duke Raleigh – 186 licensed acute care beds 85 Ambulatory Clinics HomeCare & Hospice Duke Primary Care Patient Care Facts Inpatient admissions: 60,806 Outpatient visits: 2,016,470

3. What’s happening at Duke? Opened new 7 story cancer center in February 2012 Building new 8 story Medical Pavilion w/ targeted opening for June 2013 In the process of implementing Epic in waves Ambulatory modules in five waves starting July 2012 through June 2013 924 bed hospital and revenue modules go-live July 2013 186 bed size hospital go live February 2014 369 bed size hospital go-live July 2014 In the midst of preparing for ICD-10, and planning and training efforts are not slowing down What’s happening at Duke? Lots of expensive changes Which means revenue integrity is critical!!

4. Reporting / Business Intelligence Practice Clinical Document Integrity Continuous improvement & alignment with providers, revenue cycle staff, tools, and technology Clinical Content Development Template Enhancement & Governance Revenue & Documentation Integrity Vision • Practicing Clinical Documentation Integrity • Collaboration amongst teams where the always changing regulations and impact on documentation are understood • This information can then be translated into methodologies, tools, training materials, education, metrics, and a feedback mechanism to support clinical documentation integrity within the health system • When we succeed at clinical documentation integrity then our revenue will be what it should

5. Scope of work functions would be to use understanding of regulations to complete or support the following: Develop training and communication tools Support/review clinical content changes and governance to ensure compliance with regulations (i.e. Epic templates) Understand how technology is supporting or hindering documentation integrity and utilize information for continuous improvement Review reports related to revenue and documentation metrics, investigate and determine next steps as appropriated Provide feedback to providers via appropriate forum (i.e. through compliance, clinical documentation specialists, revenue managers, etc.) Revenue & Documentation Integrity Scope

6. Documentation Integrity with Epic Epic is an integral component to our clinical documentation integrity strategy Implementing an ICD-10 Diagnosis Calculator starting in July 2012 Calculator will invoke whenever a visit diagnosis is chosen that requires additional detail for ICD-10 purposes ICD-10 Certified Trainers supporting the template build process to ensure specificity and granularity captured Incorporating ICD-10 examples into Epic provider training to ensure understanding of documentation needs Epic will be a tool to help but is not the end-all; we have to figure out the processes and resources

7. Example Dx Calculator in Epic The ICD-10 Dx calculator fires when a visit diagnosis requires additional specificity. Some examples of when the calculator invokes: When choosing a diagnosis When moving diagnosis from problem list to visit diagnosis When associating an order with a diagnosis

8. Current Situation Assessment Providers bombarded with questions/queries, etc. from multiple people for multiple purposes Managers, Director’s and leadership receive an overload of reports, some with same metrics and slightly varying answers Identified some of the documentation gaps through dual coding with current tools and chart reviews The Need We need synergy in communication with providers The messages and questions should be the same regardless of the messenger The number of people approaching providers with queries should be minimal We need alignment on what we want to monitor, how we monitor and how to act upon the business intelligence received

9. What We Are Currently Doing Developing training materials and communications for providers These materials will be utilized in various forums, including with Epic training Groups of people that communicate with providers will be trained on documentation needs and be familiar with the materials created These groups will reach out to the providers Above materials and processes will be incorporated into outpatient clinical documentation integrity program Assessed various reports reviewed by leadership to determine how to streamline the processes and communications with providers Beta site for 3M ICD-10 module and we are utilizing that application to conduct crosswalks and codes in ICD-10 Tool has helped identify gaps in documentation Purchased tool to assess risk areas due to ICD-10 transition Will use this data to focus in on areas to review for documentation gaps and to prioritize training efforts

10. Claims Analytics Assessing increases and decreases in DRG shifts Investigating those areas for documentation gaps Training those areas Assessment will also support volume and budgeting analyses

11. Revenue & Documentation Integrity Vision Reporting / Business Intelligence Practice Clinical Document Integrity Continuous improvement & alignment with providers, revenue cycle staff, tools, and technology Clinical Content Development Template Enhancement & Governance • Practicing Clinical Documentation Integrity • Accurate, complete, specific documentation in all settings of care • When we succeed at clinical documentation integrity then our revenue will be what it should

12. Questions