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This recovery strategy focuses on improving hospital revenue and performance by conducting audit reviews and implementing solutions to optimize coding practices and revenue enhancement. Key findings and impacts are analyzed for UTI/Sepsis, COPD/Pneumonia/Respiratory Failure, and Congestive Heart Failure. The solution involves educating coding staff, implementing case management programs, and monitoring Case Mix Index for continuous improvement in healthcare delivery.
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RECOVERY STRATEGY Home Town Health Anderson Goodwill Conference Center Macon, Georgia Prepared by: Sherry A. Milton, RHIA Milton & Associates, LLC Erin, Tennessee 37061 February 18, 2010
Pre-RAC Audits • SHIP HOSPITALS – NON-SHIP HOSPITALS • Sample – 30 Records • October 2007 – Present • Focused DRG List • Method of Selection – Selective • Focus RAC audit list • Review report utilizing All ICD-9-CM codes assigned • Length of Stay • Secondary codes assigned • Procedures performed (if applicable)
FINDINGS • Total Records: 148 • Pre-review CMI – 1.2679 • Post-review CMI – 1.3420 Total Changes – 61 • Decrease – 17 • Increase – 44 • Cumulative change/chart - .0741 • Total cumulative change – 10.9668 • Total Revenue Enhancement - $60,317.75
IMPACT • Recovery Audit Contractor (RAC) Impact • 11% of Total number of records reviewed • Weight Decrease – 6.3375 • Revenue - $34,850.00 • Total Impact • 41% of Total number of records reviewed • Total Weight Change – 17.3043 • Revenue Change - $95,200.00
UTI/SEPSIS • 690 – Kidney & urinary tract infections w/o MCC – Wt. .7708 • 700 – Other kidney & UTI infections w/o CC/MCC – Wt. .6533 • 699 – Other kidney & UTI infections w CC – Wt. .9518 • 698 – Other kidney & UTI Infections W MCC – Wt. 1.4877 • 872 – Septicemia w/o MV 96+ hrs w/o MCC – Wt. 1.1155 • 871 – Septicemia w/o MV 96+ hrs w MCC – Wt. 1.8437 • 870 – Septicemia w MV 96+ hours – Wt. 5.8007
COPDPneumonia Respiratory failure • 203 – Bronchitis & asthma w/o CC/MCC – Wt. .6055 • 202 – Bronchitis & asthma w CC/MCC – Wt. .8374 • 192 – COPD w/o CC/MCC – Wt. .7175 • 191 – COPD w CC - .9622 • 190 – COPD w MCC – 1.2076 • 195 – Simple Pneumonia & Pleurisy w/o CC/MCC – Wt. .7095 • 194 – Simple Pneumonia & Pleurisy w CC – Wt. .9976 • 193 – Simple Pneumonia & Pleurisy w MCC Wt. 1.4378 • 189 – Pulmonary edema & respiratory failure – Wt. 1.3455
COPDPneumoniaRespiratory Failure • 179 – Respiratory infections & inflammations w/o CC/MCC Wt. 1.2754 • 178 – Respiratory infections & inflammations w cc – Wt. 1.5636 • 177 – Respiratory infections & inflammations w MCC – 1.8444 • 208 – Respiratory system diagnosis w ventilator support < 96 hours – Wt. 2.2463 • 207 – Respiratory system diagnosis w ventilator support 96+ hours – Wt. 5.1231
Congestive Heart Failure • DRG 291 – Heart Failure and Shock with MCC – Wt. 1.4609 • DRG 292 – Heart Failure and Shock with CC – Wt. .9740 • DRG 293 – Heart Failure and Shock w/o CC/MCC – Wt. .6940
HomeTown Health Solution • EDUCATION • Coding Staff • Case Management/Documentation Specialty Staff • Ancillary Department Managers • Hospital Management • Physicians
Documentation Specialty Program • Develop Case Management/Documentation Specialty Program • Establish Top 10 DRG’s for facility • Develop hierarchy for Each DRG Set • Query Physicians concurrently • Make sure documentation is present before discharge • Manage LOS for Transfer DRG’S • Compare Coder DRG Assignment with Documentation Specialty DRG Assignment as an educational tool • Monitor Case Mix Index (CMI) as patterns develop
TODAY’S HOSPITAL ENVIRONMENT MANAGE IT PROVE IT
