2Session Goals Why Focus on Your Emergency Department. Review Emergency Department Trends.Proper Emergency Department E&M Levels.Establishing meaningful leveling methodology to capture resources.Appropriate clinical supporting documentation for levels and critical care.E.D. Patient Discharge ProcessPoint of Service CollectionsService Recovery
3Why Focus On Your Emergency Department? Front Door To The Health Care System
4Why Focus On Your Emergency Department? Major Feeder to the hospital.Greatest Source of Admissions.40-80% of Inpatient and Observation patients come from the EDEasy way to compete with less efficient hospitalsImproves Market Share: Extraordinary Patient Focused Care
5Why Focus On Your Emergency Department? Reasons for ED OvercrowdingBaby Boomers coming of Medicare age7% decrease in number of ED’s with a 32% increase in ED Visits the last 10 years.PCP shortage: National Problem, Generational DifferencesHealth care reform: Uninsured Insured, Increase in ED Visits for primary care.Safety Issues
6Crowded emergency departments linked to more deaths, costs
7Crowded emergency departments linked to more deaths, costs
8Overcrowding and Pain Management Annual ED visits have increased in the past 10 years from 90.3 to million (32% increase). With the new healthcare bill it is expected that the average ED will have increased volume of 6,500 patient visits.Number of ED’s have decreased 4019 to 3833, a 7% loss.Less ED’s and more ED visits have resulted in ED overcrowding.Pain has been deemed the “fifth vital sign” that should be routinely monitored. It is one of the leading complaints for patients in the emergency department. Knox, T. MD, MPH, Medscape Emergency Medicine Mount Sinai School of Medicine reported a study of ED overcrowding and pain management.The authors showed at peak census, that on average, patients waited 55 minutes longer for pain assessments and 43 minutes longer to receive analgesics. Hwang, U. Acad. Emergency Medicine 2008; 15: 1248 –1255CMS will monitor throughput beginning in 2011 and pay hospitals for performance.
9National Quality Forum-approved benchmarks for emergency care Centers for Medicare & Medicaid Services pilot program started 1st Qtr hospitals were the first to volunteer their data and show wide variation across the country. Reporting for all hospitals, based on a 2% pay-for-performance incentive, began Jan. 1, 2012Health Leaders Media, May 7, 2012
10National Quality Forum-approved benchmarks for emergency care The number of minutes between the time the patient arrives at the ED to the time they depart the premises of the ED to be admitted to the hospital. (ED-1)The time between the moment a decision is made by the ED physician to admit the patient to a hospital bed to the time the patient departs the ED and is actually placed in an inpatient bed, a period sometimes referred to as "boarding.“ (ED-2)Starting January 1, 2012 a third wait time measure (ED-3) for patients treated and released.Health Leaders Media, July 28, 2011
11ED-1 Measurement: Arrival to admission time on the floor Niagara Falls Memorial Hospital, Niagara Falls, NY minutesMemorial Hermann Baptist Hospital, Orange, TX minutesPerry Memorial Hospital in Perry, OK minutesPaynesville Area Hospital, Paynesville, MN minutesHealth Leaders Media, May 7, 2012
12ED-2 Measurement: ED Physician decision time to admit to admission time on the floor Memorial Hermann Baptist Hospital in Beaumont, TX minutesNiagara Falls Memorial Hospital, Niagara Falls, NY minutesFrio Regional Hospital, Pearsall, TX minutesPocahontas Memorial Hospital, Buckeye, WV minutesHealth Leaders Media, May 7, 2012
13Medical Screening Exam GOALS:Patient sign-in starts clock on the patient flow process.Greet patients as they enter the ED.Implement initial time goals:arrival to start of MSE – 5 min.arrival to disposition – 60 min averagearrival to admission / transfer – 90 min. average
17IndustryThat’s why it’s so important, in fact it is a goal of Ryerson, to keep things simple and understandable.I’d like to show you how simple it can be to improve billing protocol, how to increase revenue almost immediately, what it can mean to you long-term, and why Ryerson is the right choice -- the only choice -- to help you improve your surgical services revenue capture.In fact, we’re so confident in our ability to optimize revenue capture in surgical services departments that we only get paid once you do. Let me show you how that’s possible.
18Satisfaction with the Emergency Department by Time of Day Arrived
23What would happen if we moved discharges 2 hours earlier?
24NEDOCS National Emergency Department Overcrowding Scale Full Capacity Protocols
25NEDOCS00 to 20Not busy21 to 60Busy61 to 100Extremely busybut not overcrowded101 to 140Over-crowded141 to 180Severelyover-crowded181 to 200-DangerouslyDevelop Full Capacity Protocol Work Group of department heads and staff.Incorporate NEDOCS into your protocolInclude Clinical and Non-Clinical areas into your protocolConsider Incident Command as part of your protocol
26Effective charge captures process CHARGESEffective charge captures process
27ED CHARGES Hospitals have traditionally viewed ED’s as cost centers ED margin management typically means reducing cost, often through painful staff reductions.Hospitals can have multi-million dollar impact on their ED margins by aggressively managing top-line revenues through optimized facility evaluation and management (E/M) charges and point-of-service (POS) cash collection.Advisory Board
29ED CHARGES Documentation is key to the E/M charging process ED Directors typically do not manage the E&M charge process well.REASONS:Lack of tools and informationPoor communications with coders and HIMPoor communication or access with the business office to ensure charges are optimized.ED management needs easy access to financial information and collaboration across functional silos to be able to improve financial performance in the ED.Advisory Board
30E&M LevelingThere are no national guidelines for hospital out-patient and emergency department E&M (Evaluation & Management) coding to date.CMS has stated that each hospital must create their own guidelines.These guidelines should reasonably relate to the resources expended related to the intensity of the patient’s condition.The following is the minimal criteria for E&M leveling from CMS:
31E&M Leveling CMS E&M Criteria Follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.Be based on hospital facility resources and not on physician resources.Be clear to facilitate accurate payments and be usable for compliance purposes and auditsMeet HIPPA requirementsOnly require documentation that is clinically necessary for patient careDo not facilitate up-coding or gamingBe written or recorded, well documented, and provide the basis for selection of a specific code.Be applied consistently across patients in the clinic or ED to which they apply.Not change with frequencyBe readily available for FI (or, if applicable, Medicare administrator contractor [MAC] review)Result in coding decisions that could be verified by other hospital staff, as well as outside sources.(Source: Federal Register, Vol. 72, No.227, p66805)
32E&M Leveling Types of E&M Leveling based on: Diagnosis Time Point SystemProceduresOrA combination of some or all
33E&M Leveling Key Elements to Maximizing E&M Leveling and Charges: Develop, purchase or “Borrow” an effective leveling toolDevelop a concurrent chart review system before staff go home.Create a communication system between the HIM coder and the physician or nursing staff.Log and monitor the HIM communications with ED StaffContinually educate and remind staff regarding effective documentation.
34Note from the coder A Note from the Coder: Date:___________A Note from the Coder:Please provide the following:Dictation T-SheetDiagnosis Medical Decision MakingROS FSHHPI DispositionSignature Time of Exam Needed:Laceration Length Physician’s Order SheetIV Start/Stop time Critical Care TimePain Assessment Vital Sign SheetPhysician Order for___________________________________________________MISC:_____________________________________________________________Please return chart to ER clerical desk for re-scanning and then to bereturned to ___________(name)
38Documentation Why is documentation so important? Communicates to other caregivers what was doneFacilitates patient careSupports data collectionReflects quality of decision makingJustifies legal defenseSupports regulatory complianceSupports fair payment / reimbursementSound professional practice !
39Physician and Nursing Documentation ED physician and nursing documentation in some cases is weak or missing. The documentation does not fully support patient care, correct coding and accurate charging.Examples:Length of laceration is not always documented.IV start and stop time is often not documented.Critical care nursing time is not documented.Physicians’ charts are not always complete.Documentation does not always comply with payer and regulatory guidelines.In most cases, provided care supported higher facility E&M levels.That’s why it’s so important, in fact it is a goal of Ryerson, to keep things simple and understandable.I’d like to show you how simple it can be to improve billing protocol, how to increase revenue almost immediately, what it can mean to you long-term, and why Ryerson is the right choice -- the only choice -- to help you improve your surgical services revenue capture.In fact, we’re so confident in our ability to optimize revenue capture in surgical services departments that we only get paid once you do. Let me show you how that’s possible.
40Documentation Documenting Critical Care Critical care defines the basis for emergency medicine, yet it is the most under reported service we do!
41Documentation Definition of Critical Care CPT 99291 “Critical care is the direct delivery of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present. *CMS TRANSMITTAL 1548 JULY 9, 2008
42Documentation Critical Care Services Physician Time The CPT critical care codes and are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous.Non-continuous time for medically necessary critical care services may be aggregated. Reporting CPT code is a prerequisite to reporting CPT code Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician (§30.6.5).
43DocumentationFor CY 2011, the AMA CPT Editorial Panel is revising its guidance for the critical care codes to specifically state that, for hospital reporting purposes, critical care codes do not include the specified ancillary services.Beginning in CY 2011, hospitals that report in accordance with the CPT guidelines will begin reporting all of the ancillary services and their associated charges separately when they are provided in conjunction with critical care.Reference: Federal Register / Vol. 75, No. 226 / Wednesday, November 24, 2010 / Rules and Regulations Pg
44Documenting Critical Care We refer readers to the July 2008 OPPS quarterly update, Transmittal 1536, Change Request 6094, issued on June 19, 2008, for further clarification about the reporting of CPT codes for hospital outpatient services paid under the OPPS. In that transmittal, we note that while CPT codes generally are created to describe and report physician services, they are also used by other providers/suppliers to describe and report services that they provide. Therefore, the CPT code descriptors do not necessarily reflect the facility component of a service furnished by the hospital. Some CPT code descriptors include reference to a physician performing a service. For OPPS purposes, unless indicated otherwise, the usage of the term "physician" does not restrict the reporting of the code or application of related policies to physicians only, but applies to all practitioners, hospitals, providers, or suppliers eligible to bill the relevant CPT codes pursuant to applicable portions of the Act, the CFR, and the Medicare rules. In cases where there are separate codes for the technical component, professional component, and/or complete procedure, hospitals should report the code that represents the technical component for their facility services. If there is no separate technical component code for the service, hospitals should report the code that represents the complete procedure. Consistent with past input we have received from many hospitals, hospital associations, the APC Panel, and others, we will continue to utilize CPT codes for reporting services under the OPPS whenever possible to minimize hospitals’ reporting burden. If the AMA were to create facility-specific CPT codes for reporting visits provided in HOPDs, we would certainly consider such codes for OPPS use. CMS-1404-FC-CMS-3887-F-CMS-3835-F1 Pg
45Documentation Critical Care Billing From 1996 to 1999, 1.3% of all ER visits across the nation were billed as Critical Care.In 2000, 1.8% of all ER visits were billed as Critical Care.Real Life Scenarios —Current research shows that at least 5% to 7% of all ER visits should qualify for Critical Care billing. In 2009 the ED billed <1% Critical Care.CMS mandated that critical care nursing time be documented beginning January 1, January 1, 2009 requires nursing to document additional 30 minutes of time (99292).
46Key indicators for documenting Critical Care DocumentationKey indicators for documenting Critical CareConsider the following interventions as typical ofpatients that require critical care:Airway Monitoring CPRAny continuous monitoring IntubationCentral line placement Physical & Chemical RestraintsChest tube insertion Titration of dripsCODE STEMI protocol Patients that goes to the OR on an emergent basis
47Emergency Department Patient Discharge Process Point of Service CollectionsCollecting Past Open BalancesService Recovery
48Disposition POSC GOALS: Nursing to escort all ED patients to discharge desk.Establish a goal of $25 to be collected per discharged patient.This will increase revenue dramatically and decrease collection costs.Utilize discharge process to perform financial counseling.Re-check accuracy of registration.Service reconciliation.
49Service RecoveryIf Service recovery is needed (poor-to-fair care). “Thank you for your concerns, I apologize. I will follow up with our manager.”“Would you like our manager, name, to call you back?”
50Recognition of Staff“Mr. / Mrs. _____________ (name of patient), a last question for you: Are there any individuals whom you would like me to compliment for the care they provided? I would be happy to take their names.”Peer to Peer Recognition with this question.That’s why it’s so important, in fact it is a goal of Ryerson, to keep things simple and understandable.I’d like to show you how simple it can be to improve billing protocol, how to increase revenue almost immediately, what it can mean to you long-term, and why Ryerson is the right choice -- the only choice -- to help you improve your surgical services revenue capture.In fact, we’re so confident in our ability to optimize revenue capture in surgical services departments that we only get paid once you do. Let me show you how that’s possible.
51Final Statement to Patient “You may be receiving a survey phone call. We appreciate you taking the time to answer the survey questions as your feedback helps us to improve our care. Thank you for choosing Regional Hospital to meet your healthcare needs.”
52Dashboard Financial Charges to budget Cost to budget Materials Management shrinkagePharmacy shrinkageLevel statisticsFacilityPhysicianAmount collected at time of dischargeAccuracy of registration
53Dashboard Operations Door to triage time Door to Doc time Door to discharge timeDoor to admit timeDoctors order to admit timeAverage Radiology order to film availability time by top 10 proceduresAverage Radiology order to report timeAverage Laboratory order time to results reported by top 10 proceduresMonthly volumeTotalTreat and releaseTreat and admitTreat and transfer
54Dashboard Quality Physician Peer review Patients who return within 72 hoursNumber of charts returned to staffNumber of charts down codedQuality issues from CMS-Core MeasuresHemolysis rateLevel of cleanliness in EDIncomplete chart rateFacilityPhysicians