Nurse Executive Case Management Workshop Home Town Health Anderson Goodwill Conference Center Macon, Georgia Prepared by: Sherry A. Milton, RHIA Milton & Associates, LLC Erin, Tennessee June 22, 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 –  Post-review CMI – Total Changes – 61  Decrease – 17  Increase – 44  Cumulative change/chart  Total cumulative change –  Total Revenue Enhancement - $60,317.75

IMPACT  Recovery Audit Contractor (RAC) Impact 11% of Total number of records reviewed Weight Decrease – Revenue - $34,  Total Impact 41% of Total number of records reviewed Total Weight Change – Revenue Change - $95,200.00

HOSPITAL LIFE TODAY  Deliver high-quality care  Achieve acceptable outcomes  Reduce LOS  Be most cost-effective

Healthcare Environment  More Consumers/Patients are using the Internet to seek healthcare information.  14% of Consumers seek out the cost of treatment options on the Internet.  39% of Consumers look for information that compares treatment options.  72% of Consumers search for treatment information  Baby Boomers approaching Medicare eligible age within the next 6-7 years

MEASURES FOR COMPLIANCE  Regulatory Compliance  Physician Profiles  Hospital Profiles  DRG Assignment

Medicare Severity – MS-DRG’S  FY 2008 CMS will make significant changes to DRG systems to better reflect patient severity of illness.  Allow for better reimbursement accuracy for patients with utilization costs due to higher severity of illness.  Actually looking into what treatment costs to discourage hospitals from hand-picking healthy patients.  (Should even playing field for specialty hospitals.)

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

Payment Method  Case Mix Index (CMI) – The sum of all MS-DRG weights divided by the total cases for a given period.  Standard Rate – The average payment for a given geographic area.  Payment – Weight X rate Example DRG 292 – Heart failure and Shock W CC.9740 X = $5,357.00

MS-DRG’s LOGIC  Severity  Medical and Surgical  Same Logic  Total 989  MS DRG Triplets W/O CC/MCC W CC W MCC Constant

Principal Diagnosis Secondary Diagnoses  Principal Diagnosis – The condition after study that is responsible for occasioning the admission to the hospital.  Secondary Diagnosis  Clinical evaluation  Therapeutic treatment  Diagnostic procedure  Extended length of hospital stay  Increased nursing care and/or monitoring

Severity of Illness Complication/Co-morbidity  MCC – Major Complication Co-morbidity  Complication – A condition that arises during the hospital stay that extends the length of stay by at least 1 day in 75% of the cases.  Co-morbidity – Pre-existing condition that will extend the length of stay by at least one day in 75% of the cases because it coexists with the principal diagnosis.

MS-DRG Success  Physician documentation of pertinent diagnoses will be key.  Coding professionals will be more instrumental in achieving accurate reimbursement.  Physician query processes will need to be increased and strengthened.  Collaboration between coding and quality measure processes.

Congestive Heart Failure  DRG 291 – Heart Failure and Shock with MCC – Wt  DRG 292 – Heart Failure and Shock with CC – Wt  DRG 293 – Heart Failure and Shock w/o CC/MCC – Wt..6940

TODAY’S HOSPITAL ENVIRONMENT MANAGE IT PROVE IT