ACDIS day2-17 track4-8 pres 0515 Butler-Matacale f · 7 Motivators for Your Institution (Why?) •...

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A Full‐Time Physician Advisor Program From Zero to Sixty: Exploration, Development, Test, and Execution

Donald A. Butler, RN, BSN

Manager, Clinical Documentation Advisor Program

Vaughn M. Matacale, MD

Physician Advisor for Clinical Documentation

Vidant Health

Greenville, North Carolina

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Describe the spectrum of the physician advisor’s role and activities

– Analyze the current state of your institution’s documentation health

– Identify elements of a proposal to implement a physician advisor role/program

– Evaluate the effectiveness of a physician advisor program


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ACDIS PA Poll Data: PA Prevalence

4/11 Does your CDI program employ a

"physician champion/advisor" to help get other

physicians involved?

31%

22%

24%

16%

7%

0% 5% 10% 15% 20% 25% 30% 35%

Yes , and he/she i s very benefici a l

Yes , but he/she i s minimal l y effective

No, we would l ike to but cannot afford i t

No, we would l ike to but cannot find a

good candidate

No, we don't see the need for a

phys ician advi sor

9/14 Do you have a physician advisor to

CDI?(CDI Week 2014)

15%

46%

13%

24%

3%

0% 10% 20% 30% 40% 50%

Yes , in a ful l ‐time capacity

Yes , in a part‐time capacity

No, but we have plans to add one

No, and we have no plans to add one

Don't Know

45% 53%

61% 9/14 Rate the effectiveness of your physician

advisor (i .e., greatly improved query response rates, handles

escalated problems very well, provides successful educational

sessions, etc.)

(CDI Week 2014)

28%

29%

30%

13%

0% 5% 10% 15% 20% 25% 30% 35%

Very effective

Reasonably Effective

Somewhat effective

Ineffective

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ACDIS PA Poll Data: PA Effectiveness

True reflection? Visibility? Areas of effort? Too thin? Not clearly defined role? Competing responsibilities?

6

Motivation for Your Institution (Why?)

How do we outline and establish the need?

Can we make the broad scope of impact clear?


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Motivators for Your Institution (Why?)

• Peer‐to‐peer interface with medical staff

• DRG accuracy

– Direct chart review, clinical resource for CDI & coding staff

• Risk‐adjusted outcomes

– Value

• Risk‐adjusted outcomes/cost

– Quality and risk‐adjusted numerators

• Mortality, complications, length of stay, readmissions

– Value‐based purchasing

• Provider profiling

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Motivators for Your Institution (Why?)

• Case‐mix index

– CC/MCC capture rates

• Hierarchical Condition Category (HCC) support

• Medical necessity support

• Bundled payments

• ACOs

• RAC and auditor protection

• Coding compliance

• Changing documentation behavior at the source

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Data Sources (What?)

How do we establish the documentation health of our institution?

What can we use to benchmark?

How do we quantitate the need?


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• CDI data

– Query response and affirmation rates

• Quality department/reports

• UR reports

• Coding data

– APR‐DRG & MS‐DRG

– CMI, CC/MCC capture rates, etc.

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• RAC data

• PEPPER reports

• External databases:

– UHC & other clinical databases

– Physician & Hospital Compare websites (CMS)

– Various commercial/consult sources (Healthgrades, etc.)

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Key Players (Who?)

What will our communication and influence network look like?

Who is our sales audience?

Who will we need FOR support?

Who will we need TO support?

Can we identify the key players for success?


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Key Players (Who?)

• CFO

• CMO/VPMA

• HIMS/coding

• CDI

• Medical staff leadership

• Compliance

• Quality

• Informatics/CMIO

• UR

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Structure, Resources, and Modeling (How?)

Can we clearly outline the role and responsibilities?

What is the time commitment?

What does the time distribution look like?

How and to what extent do we educate our physician advisor?

Can we clearly outline goals?

How do we maintain our program?

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• Physician advisor responsibilities/role definition

– DRG management & case reviews

– CDI support/education

– Coder support/education

– UR leadership

– Medical staff education

– Quality role

– RAC resource

– EHR

– ICD‐10

– Case management

CDI Week 2014 survey respondents:

– Average hospital size: 333 beds

– Average CDI FTEs: 4.9


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• What makes a good PA candidate?[Very similar to a great CDS!]

– Personality

– Characteristics & experience

– Team mentality

– Specialty of MD

– Other areas of interest

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1/12 Does your physician advisor also serve as physician advisor to any

of the following additional departments? (ACDIS Journal 1/12)

51%

47%

28%

19%

11%

25%

Case management

Utilization review

Quality assurance

HIM/coding

I don’t know

Other

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9/14 What are your physician advisor’s responsibilities?

(CDI Week 2014)

16%

17%

22%

23%

26%

30%

31%

33%

33%

42%

50%

Helping to draft compliant/effective queries

Querying physicians on a concurrent or retrospective basis

Providing pre‐/post‐bill clinical documentation support

Other (please explain)

Providing documentation/clinical education to CDI and coding

staff

Offering coding/query suggestions to CDI/coding staff

Disciplining noncompliant physicians

Reviewing charts for medical necessity of inpatient admissions

Assisting with RAC appeals/drafting appeals letters

Helping to close outstanding physician queries

Assisting CDI staff with presenting documentation improvement

education to physicians


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Spectrum of Time Commitment (Must prioritize)

Possible activitiesVolunteer/minimal time

Part time

Half time

Full time

Educate medical staff (group & 1:1) YES YES YES YES

Clinical education to CDI & coding teams ? YES YES YES

Committee representation ? YES YES YES

Assist with closing queries/recalcitrant medical staff ? ? YES YES

Assist CDI/coders with specific charts/clinical issues NO ? ? YES

RAC resource (appeals, draft responses, etc.)

NO?

(FEW)?

(SOME)YES

(SOME)

EHR

ICD‐10 physician outreach/education

UR/medical necessity work (or chart reviews)

Quality/risk‐adjusted indices

Special project work (IT, medical staff interests, etc.)

Advanced CDI (outpatient, physician billing, quality, specialty, …) NO NO ? YES

Direct chart reviews (concurrent or pre‐bill) NO NO ? YES

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ACDIS PA Poll Data: PA Reimbursement

9/14 How is your Physician Advisor paid?(CDI Week 2014)

19%

49%

17%

0% 10% 20% 30% 40% 50% 60%

Not

paid/volunteer

Part‐time/paid

hourly or as

percentage of

time

Full‐

time/salaried

3/09 How is your physician advisor's

contract/reimbursement structured (60% no

PA)?

15%

33%

28%

10%

15%

0% 5% 10% 15% 20% 25% 30% 35%

Full time

Part time

Hourly rate

Based on

encounters

Other

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• Physician advisor education – sources

– External consultant

• Available consultant PA models?

– Internal training

• Available time, materials, & resources

• High expertise levels (superstar CDI & coding experts)

– Boot camps (CDI, PA, coding)

– Self‐study

– Materials

• ACDIS: PA handbook, CDS orientation book, etc.

• Coding books: ICD‐9/10, Faye Brown


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• Physician advisor education – key topics

– Coding training/credentials

– DRG management

– CDI focused

– ICD‐9 & 10

– Current clinical literature correlating with documentation challenges

– Coding concepts (e.g., PDX selection, linkage, etc.)

– CDI concepts (fundamental to advanced strategies)

– Leadership & communication training/skills

– Finance education

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ACDIS PA Poll Data: PA Training

4/13 Do your physician advisors receive

formal training?

5%

25%

70%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Yes

No

Don't Know

1/12 Does your facility provide CDI related

education to its physician advisors? (ACDIS Journal 1/12)

22%

26%

12%

40%

0% 5% 10

%

15

%

20

%

25

%

30

%

35

%

40

%

45

%

Other

I don't know what training he or

she received

Our physician advisor received

coding‐specific training

Our physician advisor received

CDI‐specific training

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ACDIS Online Poll: Orientation Time Poll

6/11 How long do you think it takes to

achieve an “EXPERT" level of proficiency

as a CDS?

1%

22%

35%

22%

6%

9%

6%

Six months

One year

Two years

Three years

Four years

Five years

More than

five years

11/09 How long did it take you to get up to

speed as a new CDI specialist?

9%

11%

16%

16%

34%

10%

3%

Immediately

1‐2 mo's

3‐4 mo's

5‐6 mo's

6‐12 mo's

1‐2 yrs

still struggling

(2+ yrs)

FULL‐TIME staff! Why would a PA be any different?


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• Networking (over time & role development)

– Introductions to key players

– Committee assignments

– Identify & get support before support is needed

• CDI/coding support for PA

• Medical & administrative leadership support

– Advertise your resource

– Active clinical practice

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• Maximizing PA function, success, & efficiency

– Equipment/space/resources

• Remote work? Office space?

• Computer, phone, etc.

• Systems & software access in timely fashion

– Supporting roles?

– Workflow and measuring progress

• Access database, EHR, coding software, other?

• Staff/time/skill set to develop and maintain data

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• Metrics & measures for performance & progress– Carefully select, design around database capabilities and staff resources

– Include:

• Analysis of institution’s documentation health

• Points that will “sell” the project

• Organizational “pain” points

– Driven by program’s formal mission, vision, & goals (SBAR)

• Examples:– Cases reviewed, accuracy rates, medical staff behaviors (clinically indeterminable rates, response rates), projects, involvements, DRG management outcomes


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• Keeping the “physician” in the physician advisor

• Physician advisor maintenance of clinical credentials– Required clinical time

– Active privileges and license

– Board certification

• Active clinical practice – Credibility

– Opportunities for informal face‐to‐face peer interactions

– Understanding of on‐the‐ground realities of documentation in the physician workflow (EHR)

– Catch the “pulse” of the medical staff

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• PA program maintenance (Quality, momentum, expertise)

– Audits

– Benchmarking with periodic reassessments

– Ongoing education & learning for PAs

• Coding, CDI, clinical

– Measures of performance

• Maintain program focus & intensity

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• Trial and analysis period

• 1‐year short‐term plan/program initiation

– Hiring, orientation, education

– Clear position description

• Firm foundation, flexible portion

• 5‐year strategic plan

– Budget

– ROI

– Hiring/growth

– Expectations, goals, milestones


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A Full‐Time Physician Advisor Program, From Zero to Sixty

Our journey:

Initial trial, analysis, development, model proposal, and execution

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Initial Trial and Analysis

Analyze state of our documentation health.

Describe the scope of our task.

Outline our basic position and structure.

Analyze our performance and identify areas of opportunity.

Make projections based on our trial period and historical data.

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Our Story: Initial Trial and Analysis

• Focused analysis

– Response & affirmation data

– UHC data comparisons,

– Case‐mix index, CC/MCC capture rates

– Mortality variable capture, case reviews

– Consultant data & activity

• Historical efforts

– PA training

– CDI program



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• Begin with one physician advisor and one manager– Health system–based

• 8 hospitals with 1,500 beds (VMC, 4 community, & 3 critical access)

• Affiliated Brody Med School

• Medical group, home health, hospice, & rehab

• 67,000 admissions

• 47,000 surgeries

• Over 1,000 providers

• 14 CDI specialists

• 30 inpatient coders

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• Explore the physician advisor position & role

– Anchor position with DRG reviews (70%)

• Post‐discharge pre‐bill

• Reviewed by consultant with feedback/education

– Remainder of the time spent on other tasks

• Education and training on CDI and DRG management

• Program and position development

• Physician and staff education

• Special projects

– Quality and mortality reviews; ICD‐10; service line education

– Other?

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• Education & training

– Didactic education with consultant

– Ongoing chart review and feedback

– Superstar resources

• Coding auditor

• Consultant support

– Self‐study & reading

– Partnership among team members

• CDI, coding, physician advisors


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• Analysis after 1 year

– Assessment of physician advisor DRG review volumes

– Calculation of DRG ROI

– Baseline of physician/medical staff behavior

• Query response rate

• Affirmation rates

• Requests for physician advisor input

– Summation of additional projects

– Summation of requests for physician advisor involvement

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Trial Period Analysis

Decreasing time available for review vs. increased administrative and project work

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Trial Period Analysis


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Building the Proposal

Identify our areas of opportunity and need for our system.

Identify the types of physicians that will make us successful.

Construct a proposal for our specific audience.

Outline short‐ and long‐term projections and goals.

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• Identified areas of need and opportunity

– Importance of managing the coded data and clinical database

– Quality

• Risk‐adjusted indices

– Medical staff buy‐in and affirmation rates

– ROI on reviews


– ICD‐10

– EHR/informatics resource

• Bridge EHR initiatives, coding, DRG, and quality

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• Build the case for program structure and size

– Calculation of possible review volumes/demographics

– FTE needs

– Projections for program building ROI/volumes, etc.

• Physician candidates

– Primarily inpatient focused

– Able to maintain clinical activity and skill on a part‐time basis


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• Additional physician advisor skill sets: Augment utility and effectiveness of the program

– Population health

– Finance and business

– Informatics/EHR

– Education

– Public speaking

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• Determine the audience

– Initial audience: Associate VP of finance and HIMS administration

• Vetting of plan and format

– Determining correct model and FTE needs

– SBAR

– Establishing support and buy‐in from CDI and coding

• Refinement of scope, budget, and numbers

• Final audience: Health system executives

– CMO

– CFO

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• 1‐year projections and short‐term goals

– DRG review volumes

– ROI

– Involvement with CDI and coders

– Expected involvement and responsibilities

– FTE additions

• Sequential addition

• Orientation and education plan

• Regional presence and networking

• Timeline for training and establishing competence

– Further analysis and program development


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• 5‐year projections and long‐term goals

– Total program FTE

– Steady state ROI

– Program maintenance goals

• Review accuracy

• Review volumes

– Standing educational appointments

• CDI and coding grand rounds

• Medical staff sessions

– More formal and regular representation to and support of related fields

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Modeled Physician Advisor FTE Needs

Hospital Pts Count Pts Core Pts Mcare Pts Mcare

Core Pts Mcaid Pts Mcaid

Core FTE Mcare

Core A FTE Mcaid

Core A FTE Pts Core A

VBFT 3737 2305 1757 1575 886 210 0.4 0.1 0.6VDUP 3766 1702 1252 1000 1435 290 0.3 0.1 0.5 VEDG 4004 2843 2041 1906 1035 351 0.5 0.1 0.8 VRCH 4501 2499 2049 1732 1228 348 0.5 0.1 0.7 VMC 45605 34840 19663 18466 10563 5706 4.9 1.5 9.3 VMC @ 75% 3.7 1.1 7.0 VMC @ 50% 2.5 0.8 4.6

ALL VH

TOTAL 100% Cases 61613 44189 26762 24679 15147 6905 6.6 1.8 11.8 Total 75% Cases 4.9 1.4 8.8 Total 50% Cases 3.3 0.9 5.9

Regional Hospitals ONLY

TOTAL 100% Cases 16008 9349 7099 6213 4584 1199 1.7 0.3 2.5 Total 75% Cases 1.2 0.2 1.9 Total 50% Cases 0.8 0.2 1.2

Model Options:

11.8 FTE All Patients all hospitals @ 100% 9.1 FTE All Medicare VMC @ 100%, All Patients Regionally @ 100% 8.8 FTE All Patients all hospitals @ 75% 6.6 FTE All Medicare, all hospitals @ 100% review (core A) 6.2 FTE VMC medicare @ 75%, regional all patients @ 100% 5.7 FTE VMC medicare @ 75%, regional Mcare & MCaid @ 100% 4.9 FTE All Medicare, all hospitals @ 75% review (core A) 4.5 FTE VMC Medicare @ 50%, regional Mcare & MCaid @ 100%

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Individual PA Progression & Impact Model

Monthly

Total Cases

Reviewed

Monthly

Independent

Cases

Reviewed

Physician

Expenses

(Labor,

benefits, etc)

Training

Costs

Share of

Program

Costs

Total

Investment

Savings From

Independent

Reviews

Independent

Case Review

Return Net

Month 1 50 0 23,333$ 11,000$ 3,400$ 37,733$ ‐$ ‐$ (37,733)$

Month 2 75 0 23,333$ 400$ 23,733$ ‐$ ‐$ (23,733)$

Month 3 100 0 23,333$ 400$ 23,733$ ‐$ ‐$ (23,733)$

Month 4 125 37 23,333$ 1,000$ 400$ 24,733$ 2,590$ 12,210$ (9,933)$

Month 5 125 37 23,333$ 1,000$ 400$ 24,733$ 2,590$ 12,210$ (9,933)$

Month 6 125 37 23,333$ 500$ 400$ 24,233$ 2,590$ 12,210$ (9,433)$

Month 7 156 58 23,333$ 500$ 400$ 24,233$ 4,060$ 19,140$ (1,033)$

Month 8 156 58 23,333$ 500$ 400$ 24,233$ 4,060$ 19,140$ (1,033)$

Month 9 156 58 23,333$ 400$ 23,733$ 4,060$ 19,140$ (533)$

Month 10 175 79 23,333$ 500$ 400$ 24,233$ 5,530$ 26,070$ 7,367$

Month 11 175 79 23,333$ 400$ 23,733$ 5,530$ 26,070$ 7,867$

Month 12 175 79 23,333$ 500$ 400$ 24,233$ 5,530$ 26,070$ 7,367$

Year 1: 1593 522 279,996$ 15,500$ 7,800$ 303,296$ 36,540$ 172,260$ (94,496)$

Month 13 200 110 23,333$ 400$ 23,733$ 7,700$ 36,300$ 20,267$

Month 14 200 110 23,333$ 400$ 23,733$ 7,700$ 36,300$ 20,267$

Month 15 200 130 23,333$ 500$ 400$ 24,233$ 9,100$ 42,900$ 27,767$

Month 16 218 142 23,333$ 400$ 23,733$ 9,940$ 46,860$ 33,067$

Month 17 218 157 23,333$ 400$ 23,733$ 10,990$ 51,810$ 39,067$

Month 18 250 180 23,333$ 500$ 400$ 24,233$ 12,600$ 59,400$ 47,767$

Month 19 250 200 23,333$ 400$ 23,733$ 14,000$ 66,000$ 56,267$

Month 20 281 225 23,333$ 400$ 23,733$ 15,750$ 74,250$ 66,267$

Month 21 281 244 23,333$ 500$ 400$ 24,233$ 17,080$ 80,520$ 73,367$

Month 22 312 271 23,333$ 400$ 23,733$ 18,970$ 89,430$ 84,667$

Month 23 312 296 23,333$ 400$ 23,733$ 20,720$ 97,680$ 94,667$

Month 24 312 296 23,333$ 500$ 400$ 24,233$ 20,720$ 97,680$ 94,167$

Year 2: 3034 2361 279,996$ 2,000$ 4,800$ 286,796$ 165,270$ 779,130$ 657,604$

Year 3: 3744 3552 279,996$ ‐$ 4,800$ 284,796$ 248,640$ 1,172,160$ 1,136,004$

Impacting Physician Query Affirmation Rate (currently 55% at VMC & Average 62% Regionally)

Note: Change d/t Affirmation is shown only on those cases reviewed by the individual PA New

Independent

Case Review

Return NEW Net

Change d/t

Affirmation

per PA

TOTAL Annual

Increase

Vidant Health

60% Year 2: 833,433$ 711,907$ 54,303$ 351,716$

65% Year 3: 1,321,344$ 1,285,188$ 149,184$ 642,264$

Difference in these two columns: First, is if the affirmation rate changes only on the charts reviewed by the PA. The second is the change if the PA is successful in approving that affirmation rate for all charts reviewed (even by vendor)

The abovedollars did not include any change in affirmation rates. If those rates change to 60% or 65% ‐‐‐ in Years 2 & 3 ‐‐ see the incremental net impact to the right. Benchmarks indicate the affirmation rate should be ~80%, so VH clearly has room to improve this metric and generate significant additional net revenue if this program is successful in its influence.

Note: Did not attempt to model (but certainly focusing upon with PA activities) the impacts improved quality and risk adjustment profiling will have from a financial standpoint.

These were discussed and presented as key concepts.


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Final PA Program Model

• Individual PAs:

– Time frame for orientation &

– Cumulative point for turnover to +ROI

• Monthly program ROI

• Goal monthly total independent cases reviewed

Month PA #1

PA #2

PA #3

PA #4

PA #5

PA ROIPA Ind Case

Volume

1 Apr-14 -100% 02 May-14 -100% 03 Jun-14 -100% 04 Jul-14 -36% 375 Aug-14 -36% 376 Sep-14 -36% 377 Oct-14 -67% 588 Nov-14 -67% 589 Dec-14 -67% 58

10 Jan-15 -12% 15311 Feb-15 -12% 15312 Mar-15 -12% 15313 Apr-15 -23% 22614 May-15 -23% 22615 Jun-15 -16% 24616 Jul-15 28% 37417 Aug-15 34% 38918 Sep-15 41% 41219 Oct-15 83% 53620 Nov-15 92% 56121 Dec-15 112% 62022 Jan-16 144% 71323 Feb-16 163% 76824 Mar-16 179% 81425 Apr-16 214% 91626 May-16 231% 96627 Jun-16 258% 104428 Jul-16 285% 112229 Aug-16 313% 120230 Sep-16 328% 124831 Oct-16 342% 128832 Nov-16 359% 133833 Dec-16 372% 137634 Jan-17 391% 143035 Feb-17 408% 148036 Mar-17 408% 148037 Apr-17 408% 148038 May-17 408% 148039 Jun-17 408% 148040 Jul-17 408% 148041 Aug-17 408% 148042 Sep-17 408% 1480

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SBAR Presentation

Present final concise proposal for senior administration.

51

SBAR Presentation


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SBAR: Situation

Recent changes in healthcare have placed increased focus

and value on the clinical database. It is the major driver for

reimbursement, resource utilization monitoring, and quality

measures. The sole source of this information is physician

documentation, and physicians have little or no training in

the rules and concepts governing this process. Increased

costs, decreased reimbursement, and more focus on quality

data have made physician education and proactive

management of the clinical database a necessity.

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SBAR: Background

• For the last 6 years an external vendor has handled our post‐discharge DRG reviews

• In FY2013 our external vendor reviewed 56% (11,000) of acute VMC Medicare charts at a cost of xx dollars per chart

• The external vendor only provides primarily DRG reviews without additional focus on quality

• Approximately 16 physicians have been trained as part‐time physician advisors (PA) since 2008 without any progress on building an internal program

• Physician education through the external vendor has had little impact and poor participation, and is at additional cost

• We are still over 95% dependent on the external vendor for our post‐discharge reviews

• Physician awareness and query affirmation rates have been relatively flat over the interval

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SBAR: Assessment

• In 2013 a total of x.xx million dollars was identified as potential gained revenue based on post‐discharge reviews (VMC only)– X.x million dollars was related to coding change recommendations, and

91% of that was recouped

– X.x million dollars was related to queries, and only 51% of that was recouped

• Best practice benchmarks estimate affirmation rate on queries should be 90%– For the past 4 years affirmation rates on queries at VMC have been

41%, 38%, 42%, and 51%

• A team of internal physician advisors could review the majority of acute Medicare charts

• A team of 6 full‐time advisors spending 75% of their time performing reviews is projected to achieve a net return on investment of over xxx,xxx dollars per month, or approximately 400%


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SBAR: Assessment

• Their remaining time would be spent on education of physicians, coders, and CDI specialists as well as focus on quality and other initiatives

• A physician advisor should reach full competency and proficiency in 18 to 24 months

• At full competency an internal physician advisor can expect to accomplish an average return of xxx dollars or more per chart and complete 2.5 or more reviews per hour

• Changing the documentation behavior of one surgical medical staff member to capture one additional comorbid condition per month could increase reimbursement by over 67,000 dollars

• The documentation of one comorbid condition per case can up to double the expected mortality on that case

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SBAR: Recommendation

Our recommendation is to form an internal Vidant Health physician advisor team.

The team would take over the majority of the post discharge pre‐bill reviews with

focus on both the DRG and quality impact of documentation and coding. Team

members would ideally have broad secondary skill sets that would complement the

program’s mission and objectives (e.g., informatics, public health, business

administration, etc.). The team would provide representation to areas within the

health system that are directly connected to or affected by the clinical database,

including quality, finance, HIMS, and IT/IS. One or more members would be

competent and skilled in utilizing the UHC database to identify areas for focus and

quality. All team members would remain clinically active and provide direct

hospital‐based patient care on a regularly scheduled basis lending clinical credibility

to the program, having a “boots on the ground” view of current clinical care, and

maintaining proficiency in the use of the EHR. This would also allow real‐time

networking and intervention during the normal workflow of the medical staff.

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A primary team function would be education of CDI specialists, coders, and medical

staff. They would be responsive to requests for analysis and focused education in

areas of concern or when data is inconsistent or below expectations. Future

growth would entail expansion of reviews to include non‐Medicare cases and

reviews primarily targeting quality‐driven initiatives.


58


Short‐term objectives• Start with the addition of 2 full‐time physician advisors and begin

their DRG training

• Identify their areas of interest and skill sets to begin training in special areas and networking

• Complete their medical staff orientation and begin clinical practice in the Vidant Health system

• Continue to develop, refine, and establish long‐term objectives

• Periodic reevaluation of progress and goals

• Strategically plan sequential addition of additional FTEs to meet long‐term program goals

• Begin networking at VMC and regional hospitals to reach medical staff with message during the “buy in” stage (underway)

59


Short‐term objectives• Analyze areas of opportunity at VMC and regional hospitals for education

and focus (underway)

• Develop support structure for training and workflow for new PAs (underway)

• Develop tools for education and clinical use to improve clinical documentation (underway)

• Begin Vidant Health new provider orientation for CDI and documentation (underway)

• Begin communication channels between CDI specialists, coders, and internal auditors (underway)

60


Long‐term objectives• Gradually expand the physician advisor team to 6 FTEs

• Perform up to 75% of Medicare post‐discharge reviews

• Establish formal communication routes between PAs, CDI specialists, and coders

• Maintain regular and consistent involvement with IT/IS, HIMS, and quality departments

• Demonstrate measurable and stable ROI for post‐discharge pre‐bill reviews

• Maintain an accuracy of 90% as measured by periodic external audits

• Provide orientation to new providers regarding CDI concepts and principles


61


Long‐term objectives

• Provide periodic “grand rounds” for documentation and coding using real examples

• Form and maintain a multidisciplinary committee to review “tough” cases to ensure consistency and compliance

• Maintain relationships, education sessions, and resources for medical staff

• Provide support for the RAC/auditing process and denials

62

Results Year 1: FY2014 & FY2015

Outline physician advisor additions.

Examine ROI and progress toward independence.

Describe projects and accomplishments.

63

Results FY2014/15: Staff

• April 2013 Physician Advisor 1 (flagship)

– Hospitalist

– Full time

– UR experience

• July 2014 Physician Advisor 2 (regional)

– Internal medicine

– Half time

• Sept 2014 Physician Advisor 3 (regional)

– Hospitalist

– Full time

– Masters in management of informatics

• Jan 2015 Physician Advisor 4 (flagship)

– Hospitalist

– Full time

– Masters in public health

• Apr 2015 Physician Assistant/ Advisor 5 (flagship)

– Nephrology, critical care

– Full time

– PHD candidate healthcare


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Results FY2014/15: DRG Reviews

# Total cases:

Actual vs. goal

# INDIE cases:

Actual vs. goal

Goal PA program net

ROI

Actual PA program net

ROI

FY14 Total 120% 152% ‐63% 8%

FY15 YTD 115% 111% ‐36% 23%

Actual performance vs. model goals

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Results FY2014/15: Projects/Education

• Medical staff presentations and education– Full, department, service line, residents, and individual

• ICD‐10– Remediation, education, networking with IT/IS

• 96‐hour rule and critical access hospitals

• Mortality reviews

• Quality impactors

• Networking and bidirectional education with CDI specialists/coders

• Clinically indeterminable rates– Systemwide initiative

• Sepsis steering committee

• Vascular SL request

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Results FY2014/15: Basic Query Indicators

Vidant Medical Center Physician Queries (All Sources)

99%

67%

13%

99%

72%

8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Response Agree Clinically Indeterminable

FY14 FY15 YTD


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Where Are We Headed?

• Definitely remain in the development phase

– Increasing requests for engagement with physicians and service lines

• Continue to build partnerships and connections

– Coding & CDI; quality

– Vidant Health medical leadership

• Major areas of unanticipated interest

– Outpatient/physician office

• Pay close attention to healthcare environment developments

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Summary: Suggestions on Starting

• Carefully examine your documentation health, current successes, and previous failures

• Use what you have to demonstrate a need

• Clearly establish scope of role & goals

• Build a clear business case

• Plan for development (program & individual)

• Need best practice examples (across role spectrum)

• Choose WISELY

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Thank you. Questions?

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.

Pre-‐Bill Review Process: Accuracy, Compliance, Op:miza:on & Educa:on

Donald A Butler, RN, BSN Manager, Clinical Documenta:on Advisor Programs Vaughn M Matacale, MD Physician Advisor, Clinical Documenta:on

Greenville NC

A key factor for success and full benefit: the ability to gather and evaluate data from pre-bill reviews. Ø Specific factors to consider:

• Categorizing the findings (what clinical & coding areas are most frequently identified) • Recording the success of actions taken, quantified outcomes (financial, CMI, ROM/SOI, etc.) • Driving findings and results to sub-categories and individuals

DATA ANALYSIS

Internal vs. External Ø What are the current processes in place, how effective, possibility for improvement or expansion

• Auditing or oversight processes for both coding & CDI? • Second level reviews (peer, manager, other; by request or other method)? • Without a current process, there is more room to increase internal effectiveness

Ø What internal resources? Level of expertise and knowledge? • Very high level of expertise, skill & knowledge base required of individuals performing reviews • Consistency, availability, flexibility to maintain an energetic process • Significant time commitment (i.e., FTE’s for direct reviews & to capitalize thoroughly the benefits)

Ø Is there a level of at least executive openness, better outright support?

Defining Populations, DRGs &/or cases to be included in a pre-bill review process: Data analysis, random vs. focused chart analysis, combination? Determine areas of weakness (Who? How?)

• Coding practice; Clinical recognition & knowledge; Over/under documented diagnosis; Complex areas; Higher areas of compliance risk; RAC/etc. areas of focus/findings; etc.

Ability to capitalize on all of the potential benefits Ø Where to prioritize internal resources for best benefit? Ø Develop avenues and tools for delivery of information learned, improvements identified Ø Key partnerships across the organization (quality, medical staff, leadership, revenue cycle) Ø Realistic Expectations – Time frames, outcomes, longevity

Possible Expanded Scope Ø Formalized auditing process for query compliance Ø Application of data & auditing to individual employee development, monitoring & performance rating. Ø Fine tuned guidance toward Medical Staff education & collaboration

ADDITIONAL CONSIDERATIONS

Simply Defined: Ø Expert clinical & coding case review after final coding & prior to billing. Purpose: Ø Accuracy

• Complete & accurate medical record documentation that appropriately reflects provided services • To the greatest degree of specificity clinically supported

Ø Compliance • Coding guidelines, coding clinic, etc. followed • Query presentation, content, etc. • Clinical validation

Ø Optimization • Most appropriate MS-DRG & code assignment for each case, leading to fully appropriate revenue & risk adjusted profiling that supports LOS, service intensity, ROM & resource utilization

• Efficiency, accuracy & knowledge of internal staff & processes Ø Education

• Daily feedback in the form of case specific recommendations • Periodic on site or webinar education sessions focused on our specific educational needs

• (based on chart findings as well as broader trends & changes) • Consultant’s staff available for discussion of any questions or concerns (case specific and general)

CONCEPTS / DISCUSSION

In 2009 we were looking for ways to grow the proficiency and outcomes of our program. At that point we were not engaged with a consultant. After conversations with other hospitals and evaluating several consultants, we further examined the services offered by Dr Garry Huff (Huff DRG Review). Ø Customized menu of services, tailored to our needs and choices Ø We initially started to development of a group of Physician Advisors (which included pre-bill review

services as part of training and development of the PA’s) Ø By the mid-point of 2010 we considered to spin off pre-bill chart review services, we began

engagement and were ramped up by the end of the fall

BACKGROUND Ø Data driven focused case selection Ø 24 hour turn around by external consultant for reviewed cases Ø Close communication & discussion surrounding recommendations Ø Actions closely monitored by leadership

PROCESS Pre-Screening Process In mid FY12, observing a trend of slightly lower ROI, conducted data analysis of the reviewed cases by DRG to determine both the frequency and quantified impact of recommendations.

• Utilized this data to develop an individual pre-screening process prior to forwarding for review. • Cases reviewed were limited to those DRG’s with a lower frequency of findings (both potential improved DRG as well as compliance issues).

• Individual Case decisions (review vs bill) are made based on abbreviated direct chart review. • Initiated process in 4th Qtr FY12, has resulted in a higher ROI and stabilized recommendation rate.

Case Focus List: as data supports, selected DRGs are removed from the target population. Improvements with Case Feedback & Review

• Forwarded daily to coding staff for review and action – core process element. • Case sharing with CDS’s had 2 areas of focus – a clerical staff member collects cases and forwards weekly to each CDS; selected findings were identified for group presentation.

Query Process – several developments and enhancements • Transition of queries toward inclusion of queries in the chart deficiency & suspension process • Increased collaborative process between CDI & Coding staff

PROCESS REFINEMENT EXAMPLES:

Ø We have expanded CDI programs & Pre-Bill reviews to all of our Acute Inpatient Hospitals (2012/13) Ø Continued leverage and improvement of data processing Ø Develop internal Physician Advisor skill sets (2014) -- Dedicated FTEs (50% of time or more);

• Pre-bill chart reviews • Influence medical staff behavior • Education and collaboration with multiple stakeholders • Resource to CDI/Coding team • ICD-10 communication & preparation;

Ø Leveraging and applying Pre-bill Reviews as part of ICD-10 preparation and analysis

NEXT & FUTURE STEPS

Ø Clear, consistent ROI –positive financial impacts & improved compliant coding, sequencing, etc. Ø Improvement in O/E Mortality rating within University Healthsystems Consortium Ø Education:

• Over time, identification of several previously unknown / missed strategies that we were able to rapidly include into our normal processes

• Periodic formal seminars focused upon clinical topics, coding expertise and industry developments (with AHIMA CEU’s awarded)

• Analytical identification of areas of weakness with corresponding improvements • Internal educational publications:

• Monthly Documentation Tip (primary focus medical staff, also good for CDI/coding teams); • Coding Newsletter & Coding Tips. • Development of standard clinical topic references, models & query references.

Ø One of several key factors in guiding and informing standard coding practice Ø Support with successful defense with RAC (& others) findings.

(At least in part, if not completely, deriving from the ability to demonstrate ongoing objective value of CDI efforts through good data & outcomes; as well as identify & measure additional opportunities) Ø Executive Physician Champion (2011) Ø Growth of CDI team (serial growth of CDI team from 7 to 11 FTE’s) Ø Coding Educator FTE (2013) Ø Significant benefit toward establishment of internal Coding Training Academy (2013)

REALIZED DIRECT BENEFITS

COLLATERAL BENEFITS:

Ø Conversion of possible ROI to actual

• (largest factor is physician response; additionally -- need for consistent implementation of actions, process oversight, understanding & knowledge of staff influence)

Ø Driving education/findings into practice change (coding, CDI & medical staff) Ø Periodic need to recycle through recurring clinical topics

• (both as a large teaching hospital as well as aspects of cultural change processes) Ø Maintaining the ongoing momentum and progress.

CHALLENGES:

Coding Finalized

Automated DRG based Screening & pre-bill hold • Selection based on historical data, periodically updated with assessment of pre-bill review results & consultant client data base • A yes/no decision for all cases in each DRG

Analytical Manual Screening • CDAP Manager, expertise in CDI & coding competence • Based on years of pre-bill data • Case by case quick review & decision

YES

NO

Billed

Pre-bill review Focus: • DRG & Code Validation • Clinical Validation • Provide recommendations

o Coding change o Query needed o FYI/feedback

Pre-bill review process: • 1 business day turn around • Conducted by highly expert coding & clinically astute staff • Individual reviewed by CCS certified physician experts

Recommendation?

YES

Billed Conversation, further review, learning, etc. until agreement

NO

NO YES Appropriate actions completed, results of queries obtained and coded, etc.

Release for billing?

Reviewed, understood & agreed • Coding leadership manages flow & oversight • Results returned to individual coder for action & CDIS review

Pre-Bill Review Process Outline

Pre Bill Review Outcomes

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Pre-Bill Review Outcomes

Pre Bill Review Measures

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% of Discharges (after automated & manual screening) Recommendation % Rate

Pre-Bill Review Measures

ACDIS day2-17 track4-8 pres 0515 Butler-Matacale f · 7 Motivators for Your Institution (Why?) •...

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