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

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

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3. 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

4. Prepared by MPA Consulting 4 Managing effectively in this extraordinarily changing environment Assess your facility’s environment Identify the issues Create a dashboard Prioritize the issues Establish an action plan Get going!

5. 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?

6. 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!

9. 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”

10. 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”?

11. RATE YOURSELF ON MS-DRGs

12. 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

13. 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)

14. 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

15. 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

16. 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

17. POA and Never Events Establish a query process to obtain clarification regarding POA if needed to assign a reason code Note: Medicare’s MedLearn Matters #5499 states that “Issues related to inconsistent, missing, conflicting or unclear documentation must still be resolved by the provider.”

18. RATE YOURSELF ON POA AND NEVER EVENTS

19. 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!

20. RATE YOURSELF ON CMI

21. 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?

22. CDI Best Practice Concurrent queries “Marriage” of HIM/Coding and Case Management Concurrent documentation by physicians Performance monitoring of queries, responses and financial impact

24. RATE YOURSELF ON CDI

25. 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

26. 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.

27. RATE YOURSELF ON DNFB

28. 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

29. 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?

30. Coder Recruitment and Certification Do you use contract coders? Are they certified? Is their continuing education up to date? Are they oriented to your facility’s coding policies and procedures?

31. RATE YOURSELF ON CODING RECRUITMENT AND CERTIFICATION

32. 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?

33. 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

34. Coding Staffing and Productivity

35. RATE YOUR CODING STAFFING AND PRODUCTIVITY

36. 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?

37. 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

38. Coding Accuracy Are there internal and external audits at least annually? Accuracy rates should exceed 95% at the DRG and APC level

39. RATE YOURSELF ON CODING ACCURACY

40. You can manage effectively in this changing environment Create a dashboard Prioritize the issues Establish an action plan Get going!

41. QUESTIONS ? For further information please do not hesitate to contact me: Kim Murphy-Abdouch (210) 826-2851 kmurphy@mpa-consulting.com THANK YOU!!