| |
Our client, located on two hospital campuses, retained Sinaiko Healthcare Consulting, Inc. (“Sinaiko”) to conduct a Phase One analysis to identify documentation and coding opportunities for the Summit and Alta Bates campuses related to current performance impacting MS-DRGs and other documentation related issues. This analysis was based on each campus’s respective top ten (10) MS-DRGs. The MS-DRGs to be reviewed were determined not only by their admission volume but also included those that carried the highest financial and/or documentation or compliance risk. Secondary volume diagnoses data was also analyzed to determine the volume and/or percentage of cases that captured complications and/or co-morbidities (“CCs”) that have now been deleted under the MS-DRG system as well as those that have been added under the new system.
The analysis was based on two principal components: (1) an audit; and (2) on-site observations and interviews. Our audit was designed to determine if physician documentation present in the chart supported Present on Admission (POA) diagnoses, principal and secondary diagnoses with emphasis on Major Complication/Co-morbidity (MCC), and Complication/Co-morbidity (CC) documentation/coding. In addition, we assessed the medical record for missed opportunities in clarifying conditions and/or including specificity or a condition that could have provided a more accurate medical record. Our analysis focused on identifying revenue impact and other opportunities for improvement in the areas of documentation and coding.
The key findings resulting from the comprehensive onsite analysis were in several areas:
Documentation deficiencies were found in the Physician Query Process, Physician Documentation, Length of Stay, and clinical support staff involvement in the process. Coding issues were found for Present On Admission, and Principal and Secondary Diagnosis Code Assignments. Sinaiko’s findings indicated the quantification of the impact upon expected reimbursement from both documentation error and coding error perspectives. The “documentation” errors and omissions identified during the course of the project were quantified based on the understanding that the Health Information Management (HIM) coders did not have the sufficient information from which to code and therefore services were coded at a lower level than would have otherwise been possible had the documentation been complete. The “coding” specific findings were quantified based on identified coding issues from the UB-04 billing forms. These were cases in which Sinaiko auditors found support in the existing documentation for differences in coding.
Interview observation findings included a disparity in the Physician Query Processes, Length of Stay Target, Nursing and Care Coordination Supporting Physician Documentation, and specific documentation findings within the History and Physical, Admission Status, Legibility and Progress Note Format, Physician Orders, Operative /Procedure Notes, Discharge Summary, Lack of Specificity of Severity, Lack of POA Documentation, and the Lack of Physician Interpretation of the Condition and of Abnormal Diagnostic Results. As this situation indicates solid, value-focused clinical documentation improvement program concentrated on establishing meaningful quick start improvements to current physician documentation practices could clearly pave the way to positive sustainable improved results, including improved appropriate, compliant revenue capture. Sinaiko ultimately recommended proceeding with our concurrent documentation improvement (CDI) program in order to assist the organization with education based on our findings, and implementation of our recommended changes to achieve sustainable efficiencies, as well as accurate coding based on documentation. |
