Eric Ryland, RHIA, CHDA, CCS, CPC

Manager of Coding

Denver Health Medical Center

Denver, CO

Metrics: Measuring the Impact of CDI and Coder Contributions

Our Facility

• Denver Health is a level one trauma center

• Located in downtown Denver

• 477 beds

• Multiple hospital-based specialty clinics

• Multiple community healthcare centers

• Medicaid & uninsured are our largest payer groups

• Medicare is our third largest payer

• Teaching facility utilizing residents

Coding Area

• One coding manager and two assistant managers

• 25 coders – inpatient & outpatient

• Two outsourcing companies providing additional coverage for staff vacations and training time

• We code for inpatient DRG accounts, observations, ambulatory surgeries, emergency department account, and for the specialty clinics

• 5-day turnaround time for coding

CDI Area

• One CDI nurse manger

• Three CDI nurses working part time for an equivalent of 2 FTEs

• Primary focus is our Medicare & Medicaid patients

• CDI staff report to the HIM director

• CDI staff attend the monthly coding meetings and maintain a high level of communication with the coding staff

Core Measures & PSI Staff

• Core measures & PSI staff are located in the quality department and report up to the CQO

• One nurse reviews core measures data

• One nurse reviews accounts for PSI, HAC, SOI, and ROM

• The quality department nurses frequently attend coding meetings

Goal

• We want to be able to demonstrate the success of the efforts made by the CDI and the coding staff. This helps:

– Justify the funding for the CDI program

– Support the argument for highly trained coders

– Identify areas of improvement within the CDI or coding teams

– Create a feedback loop between the CDI staff, the coding staff, and the downstream users of the coded data

Who Are the Interested Parties?

• CDI manager

• Coding manager

• HIM director

• Utilization management

• CFO

• Others

What Are the Areas We Are Looking At?

DRG Diagnosis-related groups

MCC Major comorbid condition

CC Comorbid condition

SOI Severity of illness

ROM Risk of mortality

HAC Hospital-acquired condition

PSI Patient safety indicator

Core measures

Quality of care

Other areas UM, discharge disposition

How Do We Go About Measuring for So Many Areas?

• We must determine what area we wish to measure from

– CDI staff, coders, quality staff, etc.

• We must select a metric to quantify our results

– Number of changes, $$$, CMI, etc.

• We must determine the point in the process to measure at and how to capture that data

– Manually collect data or capture data from systems reports

Who? How? When?

• Who?

– The areas measured for effectiveness• Chosen by need to demonstrate effectiveness

• How?

– Using metrics• Chosen by usefulness and an ability to calculate

• When?

– At valued-added points• Determined by reviewing process flow charts

CDI Committee

• Physician advisor

• CDI manager

• CDI nurses

• Coding manager

• Inpatient coding educator

• HIM director

• Utilization management director

• Quality measures nurses

Flow Chart Process

• Flow-chart from the beginning with CDI to final data item

• Create a master flow chart that incorporates the flows of all endpoint data items

• This allows you to identify the points along the way where each area plays a role

• With the flow chart you can then visualize how to begin measuring the successful efforts of the people involved in the process

CDI Flow Chart

CDI & Coding Flow Chart

HAC Flow Chart

PSI & Core Measures Flow Chart

Identifying the Points of Measurement

Patient Admitted

CDIDocumentation

ReviewProcess Patient

Discharged

Coding

Query

AccountCoded

PhysicianResponds

To Query

Yes

No

Value Added

Value Added

How to Quantify the Measurements?

• Numerical count

– A simple count of the number of changes

– Can also be expressed as a percentage

• Dollar increase/decrease

– Revenue increase or decrease resulting from a DRG change

• Change in CMI, SOI, ROM, core measures

– Showing initial and final aggregate scores

Revenue Increase

CaseInitial DRG

ReimbursementFinal DRG

ReimbursementResulting Change

1 328 $7,214.45 326 $29,592.89 $22,378.442 412 $12,495.56 411 $18,661.81 $6,166.253 184 $5,254.54 183 $7,655.71 $2,401.17

$30,945.86Total Change

DRG Relative Weight Changes

CaseInitial DRG

DRG Relative Weight

Final DRG

DRG Relative Weight

1 328 1.3848 326 5.68032 412 2.3985 411 3.58213 184 1.0086 183 1.4695

Calculating Aggregate CMI Change

CaseInitial DRG

DRG Relative Weight

Final DRG

DRG Relative Weight

1 328 1.3848 326 5.68032 412 2.3985 411 3.58213 184 1.0086 183 1.46954 103 0.6677 103 0.66775 150 1.3103 150 1.3103

Initial CMI 1.3540 Final CMI 2.5420

87.74%Percentage Increase in CMI

Metrics for Measurement

Data ItemNumerical Measure

Dollar Impact

CMI

DRG # $ YesMCC # $ YesCC # $ YesSOI #

ROM #HAC # Reduced $ YesPSI # Reduced $ + or - Yes

Core Measures # Reduced $ + or - Yes

Methods of Metrics Gathering

• Manual

– Spreadsheets• Time-consuming with potential for data entry errors

• Software

– Run reports• May be limited to a single software system

• A data warehouse can consolidate systems data

• Combination

– Software-generated reports integrated with spreadsheet data• Most prevalent situation

Our Model for Data Collection

Our CDI Results

2011Total

ReviewsConcurrent

Queries Patients

Reviewed

Medicare Patients

ReviewedAdditional

ReimbursementAugust 176 45 8.50% 29% $74,327September 157 58 7.70% 25% $184,471October 224 52 10.90% 34% $66,125November 155 44 7.70% 25% $35,043

CDI Query Results

4th Qtr. 2011

• Query rate

– 26%

• Physician response rate

– 78.2%

• Physician agrees with query

– 82%

• Financial impact rate

– 6.8%

Our Coding Results

Retrospective Queries

Additional CC

Additional MCC

DRG Impact

113 47 23 51

2011

Our HAC Results

2011 HACs Reviewed HACs ChangedJanuary 4 1February 4 1March 2 0April 6 4May 1 0June 9 2July 4 0August 2 0September 7 0

Our PSI Results

2011 PSIs Reviewed PSIs ChangedJanuary 21 1February 21 1March 18 0April 11 0May 10 0June 21 0July 30 0August 16 1September 30 6

Our Core Measures Results

Reviews

Coding Changes

from Reviews

Addendums Dictated

Coding Changes

from Addendums

Review Impact

36 12 10 7 52.8%

2011

# of Visits Reviewed

AUG SEP OCT NOV DEC0

50

100

150

200

250

# of Visits Reviewed

Total # of Reviews

AUG SEP OCT NOV DEC0

50

100

150

200

250

300

350 Total # of Reviews

Total # of Queries

AUG SEP OCT NOV DEC0

10

20

30

40

50

60

70

Total # of Queries

Reimbursement Impact

AUG SEP OCT NOV DEC$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

$160,000

$180,000

$200,000

Reimbursement Impact

MCC/CC Capture Rate

AUG SEP OCT NOV DEC0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

MCC/CC Capture Rate

Query Rate

AUG SEP OCT NOV DEC0%

5%

10%

15%

20%

25%

30%

35%

40%

Query Rate

Physician Response Rate

AUG SEP OCT NOV DEC68.0%

70.0%

72.0%

74.0%

76.0%

78.0%

80.0%

82.0%

84.0%

Physician Response Rate

Agreement Rate

AUG SEP OCT NOV DEC0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Agreement Rate

Reporting Frequency

• Monthly reports are created and reviewed by the coding manager, CDI manager, HIM director, and the quality department nurses

• Quarterly & annual reports are created and prepared for presentation to the CFO, CQO, and CIO

• Weekly reports are generated on accounts with outstanding queries, missing dictations, and disparities between the CDI DRG and the coding DRG

Lessons Learned

• Capturing metrics through software saves time and resources

• Developing our metrics helped us streamline both the CDI and the coding work flows

• Our CDI metrics gave us insights into where we could look to improve our efforts

• The metrics gave us support for additional training of our coders

• Developing metrics has helped create a more cooperative environment between the areas involved

What to Look for in Choosing Software

• Know what data you want to capture and how you want to report it

• Look for software that has the reporting capabilities you are looking for

• Determine whether you are looking for a database to enter your data or a more dynamic system that interacts with other areas like coding

• If the software allows you to create your own reports, consider a system that doesn’t use a proprietary report writing language

Resources

• MS-DRG weights from 2012 IPPS Final Rule

– https://www.cms.gov/AcuteInpatientPPS/FR2012/list.asp#TopOfPage

• HACs

– https://www.cms.gov/HospitalAcqCond/downloads/HACFactsheet.pdf

• SOI overview

– http://www.ahrq.gov/qual/mortality/Hughessumm.htm

Contact Information

Eric Ryland, RHIA, CHDA, CCS, CPCeric.ryland@dhha.org

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