Emergency Services

Session 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 Process Point of Service Collections Service Recovery

Why Focus On Your Emergency Department? Front Door To The Health Care System

Why Focus On Your Emergency Department? Major Feeder to the hospital. Greatest Source of Admissions. 40-80% of Inpatient and Observation patients come from the ED Easy way to compete with less efficient hospitals Improves Market Share: Extraordinary Patient Focused Care

Why Focus On Your Emergency Department? Reasons for ED Overcrowding Baby Boomers coming of Medicare age 7% decrease in number of ED’s with a 32% increase in ED Visits the last 10 years. PCP shortage: National Problem, Generational Differences Health care reform: Uninsured Insured, Increase in ED Visits for primary care. Safety Issues

Crowded emergency departments linked to more deaths, costs

Crowded emergency departments linked to more deaths, costs

Overcrowding and Pain Management Annual ED visits have increased in the past 10 years from 90.3 to 119.2 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. 2009 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 –1255 CMS will monitor throughput beginning in 2011 and pay hospitals for performance.

National Quality Forum-approved benchmarks for emergency care Centers for Medicare & Medicaid Services pilot program started 1st Qtr 2011 74 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, 2012 Health Leaders Media, May 7, 2012

National 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

ED-1 Measurement: Arrival to admission time on the floor Niagara Falls Memorial Hospital, Niagara Falls, NY 387 minutes Memorial Hermann Baptist Hospital, Orange, TX 358 minutes Perry Memorial Hospital in Perry, OK 52 minutes Paynesville Area Hospital, Paynesville, MN 90 minutes Health Leaders Media, May 7, 2012

ED-2 Measurement: ED Physician decision time to admit to admission time on the floor Memorial Hermann Baptist Hospital in Beaumont, TX 170 minutes Niagara Falls Memorial Hospital, Niagara Falls, NY 170 minutes Frio Regional Hospital, Pearsall, TX 0 minutes Pocahontas Memorial Hospital, Buckeye, WV 0 minutes Health Leaders Media, May 7, 2012

Medical 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 average arrival to admission / transfer – 90 min. average

Customer Satisfaction

in the Emergency Department The Less Satisfied the Patient The More Time Spent in the Emergency Department The Less Satisfied the Patient The amount of time spent in the ED is a critical factor in the overall satisfaction of ED patients. The following graph shows that satisfaction declines dramatically after two hours and continues to fall with each additional hour. Represents the experiences of 1,524,726 patients treated at 1,656 EDs nationwide between January 1 and December 31, 2007. Emergency Department Pulse Report © 2008 by Press Ganey Associates, Inc.

Lost Revenue compared to % LWBS

Industry 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.

Satisfaction with the Emergency Department by Time of Day Arrived

Hospital activity by hour of day

Peak In-Patient Discharge time

Peak In-Patient Admission Time

Peak In-Patient Admission and Discharge Time

What would happen if we moved discharges 2 hours earlier?

NEDOCS National Emergency Department Overcrowding Scale Full Capacity Protocols http://hsc.unm.edu/emermed/nedocs_fin.shtml

NEDOCS 00 to 20 Not busy 21 to 60 Busy 61 to 100 Extremely busy but not overcrowded 101 to 140 Over-crowded 141 to 180 Severely over-crowded 181 to 200-Dangerously Develop Full Capacity Protocol Work Group of department heads and staff. Incorporate NEDOCS into your protocol Include Clinical and Non-Clinical areas into your protocol Consider Incident Command as part of your protocol

Effective charge captures process CHARGES Effective charge captures process

ED 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

ED CHARGES Source: Advisory Board

ED 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 information Poor communications with coders and HIM Poor 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

E&M Leveling There 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:  

E&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 audits Meet HIPPA requirements Only require documentation that is clinically necessary for patient care Do not facilitate up-coding or gaming Be 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 frequency Be 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)

E&M Leveling Types of E&M Leveling based on: Diagnosis Time Point System Procedures Or A combination of some or all

E&M Leveling Key Elements to Maximizing E&M Leveling and Charges: Develop, purchase or “Borrow” an effective leveling tool Develop 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 Staff Continually educate and remind staff regarding effective documentation.

Note from the coder A Note from the Coder: Date:___________ A Note from the Coder:   Please provide the following: Dictation T-Sheet Diagnosis Medical Decision Making ROS FSH HPI Disposition Signature Time of Exam Needed: Laceration Length Physician’s Order Sheet IV Start/Stop time Critical Care Time Pain Assessment Vital Sign Sheet Physician Order for___________________________________________________ MISC:_____________________________________________________________ Please return chart to ER clerical desk for re-scanning and then to be returned to ___________(name)

E&M Leveling

Charge Master CDM could have approximately 450 line items for procedures Avoid low, moderate, complex bundled charges Be sure that bundled procedure charges exceed Medicare Fee schedule

Documentation

Documentation Why is documentation so important? Communicates to other caregivers what was done Facilitates patient care Supports data collection Reflects quality of decision making Justifies legal defense Supports regulatory compliance Supports fair payment / reimbursement Sound professional practice !

Physician 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.

Documentation Documenting Critical Care Critical care defines the basis for emergency medicine, yet it is the most under reported service we do!

Documentation 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 http://www.cms.hhs.gov/Transmittals/Downloads/R1548CP.pdf

Documentation Critical Care Services Physician Time The CPT critical care codes 99291 and 99292 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 99291 is a prerequisite to reporting CPT code 99292. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician (§30.6.5).

Documentation For 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. 71988

Documenting 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 741 - 742

Documentation 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, 2007. January 1, 2009 requires nursing to document additional 30 minutes of time (99292).

Key indicators for documenting Critical Care Documentation Key indicators for documenting Critical Care Consider the following interventions as typical of patients that require critical care: Airway Monitoring CPR Any continuous monitoring Intubation Central line placement Physical & Chemical Restraints Chest tube insertion Titration of drips CODE STEMI protocol Patients that goes to the OR on an emergent basis

Emergency Department Patient Discharge Process Point of Service Collections Collecting Past Open Balances Service Recovery

Disposition 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.

Service Recovery If 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?”

Recognition 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.

Final 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.”

Dashboard Financial Charges to budget Cost to budget Materials Management shrinkage Pharmacy shrinkage Level statistics Facility Physician Amount collected at time of discharge Accuracy of registration  

Dashboard Operations Door to triage time Door to Doc time Door to discharge time Door to admit time Doctors order to admit time Average Radiology order to film availability time by top 10 procedures Average Radiology order to report time Average Laboratory order time to results reported by top 10 procedures Monthly volume Total Treat and release Treat and admit Treat and transfer  

Dashboard Quality Physician Peer review Patients who return within 72 hours Number of charts returned to staff Number of charts down coded Quality issues from CMS-Core Measures Hemolysis rate Level of cleanliness in ED Incomplete chart rate Facility Physicians  

Dashboard Patient Satisfaction Press Ganey quarterly report AMA LWBS Patient complaints Results from patient survey Physician complaints Nursing complaints

Thank You