Expert System Helps Increase Reimbursements While Cutting Down Coding Time at Hospital
By Ceil Heckler,
Medical Records Director
Windber Hospital, Pennsylvania
Windber Hospital increased Medicare/Medicaid reimbursements by coding DRGs (diagnosis related groupings) with a computer, and also reduced the time to code a typical patient record by 10%. An expert software system replaced hand coding methods and guides the user to select a more precise diagnosis as substantiated by the medical records. In a typical example, the new system prompted the user to reexamine a respiratory patient record in more detail, and a complication was discovered which tripled the reimbursement level over what would have been obtained with manual methods. In addition, the hospital now automatically matches ICD-9 codes with CPT-4 coding, virtually eliminating errors stemming from mismatched codes.
Windber Hospital is a full-service 99 bed community hospital located in Southwestern Pennsylvania. The hospital serves residents of Johnstown and surrounding communities within a 50 mile area. The facility has 29 active medical staff and 60 consulting and courtesy staff. They also operate a regional hospice and a chemotherapy treatment center affiliated with Laurel Highlands Cancer Program.
In the past the hospital used a combination of computerized and manual techniques. The computer system in place at the time didn't have encoding capabilities but was simply a word-processing tool to assemble the documents. Staff began the process by manually searching the index in the ICD-9-CM manual for a diagnosis. If the terminology used by the staff member didn't match the manual's, they were referred to another section. Many times, the staff member would have to flip through several different pages and categories, often being directed to additional references. It was easy to make mistakes and not get the right codes for a diagnosis, or to miss the sign that a fifth digit for a more specific diagnosis was needed. Once the staff member selected a code to the best of his or her ability, they entered the information and printed the document. This multi-step procedure took up valuable staff time and was prone to error. The result was that inaccurate and missed diagnoses caused the hospital to receive less reimbursement than it was entitled to from Medicare, Medicaid, and private payers. Many times charts were inaccurately coded and in most cases the errors resulted in underpayment. To further complicate the situation, the software vendor went out of business leaving the hospital with no upgrades or support.
In late 1994, the Medical Records Department set a goal to improve coding accuracy and decrease the time spent coding. Hospital staff sought an encoding package to supplement Citation, an in-house information management system used for order entry, abstracting, and in-house billing. The software designers sub-contracted with IRP Systems, Wilmington, Massachusetts to provide Clinical Coding Expert software -- a DRG encoder which incorporates the entire ICD-9-CM and CPT-4 coding book on a computer. Once the user switches from Citation to Clinical Coding Expert, the process begins by entering identifying information such as the patient's age, gender, date of admission, date of discharge, etc. Then the user simply types in the principal diagnosis from the chart. For example, for a rib fracture the user types in "fracture" and the software immediately displays the alphabetical listing of fractures and their codes in the ICD-9-CM code book. At that screen the user types in "rib" and pushes the enter key. The computer automatically provides the code for a rib fracture, 807.0. Compared to stumbling through a manual, this process is nearly instantaneous. Even though most of the medical records staff had never used such a system, it proved to be very easy to learn because it prompts the user throughout the coding process.
Windber Hospital's expert system contains over 6,000 rules that were derived and verified from analysis of 20 million case abstracts. These rules are applied against the case currently being coded. The current case is analyzed for clinical conditions that indicate whether a more detailed review of the chart is warranted to improve DRG reimbursement or to improve adherence to coding guidelines. If additional review is determined, the system identifies specific complications, co-morbidities, secondary diagnoses and related procedures which may be present in the chart but have not been coded. As a result, the coder is prompted to review only those charts which have been screened for likely coding improvement instead of all charts. The list of suggested diagnoses and procedures is tailored to be clinically relevant to the chart being coded. Factors such as patient gender, age, diagnoses, procedures and discharge status are used to fine tune the data. The addition of a missing element is a simple matter of selecting it from the list shown. Any time the current chart is modified, a new set of rules is calculated. If clinically appropriate, new selection lists are presented and the process is repeated.
One of the main benefits of this system for Windber Hospital is that it guides the coder to select a more precise diagnosis as substantiated by the medical record documentation. Frequently, this results in a higher reimbursement level than if the simpler alternative was selected manually. For example, the coding manual uses a little sign to indicate whether a diagnosis needs a fifth digit. This digit is a more specific code that speeds up and often increases reimbursements. However, the sign in the manual is easy to miss. With Clinical Coding Expert, when the coder hits the enter key, the software immediately gives the fifth digit if it is needed. In the example of the rib fracture, once the code for rib fracture is displayed, the screen also lists the fifth digit for all possible variations of rib fracture such as one rib broken, two ribs broken, sternum also broken, and so on.
The software also helps identify complications. Working by hand, the principal diagnosis itself is so difficult to determine that there is a great temptation to stop there. The software reminds the user that no complications have yet been entered, determines whether each item entered qualifies as a complication, and suggests possibilities. In many cases, these complications are items the person doing the coding manually may not consider. Because Clinical Coding Expert clearly demonstrates on the screen other possible, alternative DRG assignments, this helps the coder review records to see if a secondary diagnosis, with a higher DRG reimbursement, could actually be the principal diagnosis. In a recent case, the system alerted the user that a patient with acute respiratory distress had also been treated with a ventilator and endotrachial tube. Thus, the hospital received reimbursements three times greater than it would have if just the acute respiratory distress had been coded. If coding manually, the coder might forget to look for the ventilator treatment. As another example, if a patient was diagnosed with congestive heart failure, the system would inform the medical records staff that in a majority of patients with heart failure, an existing co-morbid condition is also present which would raise the reimbursement level. This prompts the user to look through the patient's record again to see if the condition exists.
Another benefit of the new system is the cross-walk feature which automatically matches the ICD-9 codes with appropriate CPT-4 coding. Medical records staff uses ICD-9 coding for both in- and outpatient, but also codes out-patients with CPT- 4 procedures. In prior years, it was difficult for the medical records staff to find the CPT- 4 code that accurately corresponds to ICD-9 coding. A staff member spent his or her valuable time flipping from one book to the other, searching indexes, only to select a matched code with mixed results. Now the user simply calls up the outpatient record, enters the ICD-9 code, and the appropriate matching CPT-4 coding is instantly displayed. Users can also translate matching codes in reverse. Errors stemming from mismatched codes have been virtually eliminated, and the time to match codes has been significantly reduced.
The medical records department also appreciates the on-screen explanations of why a certain code was suggested. Instead of fumbling through several thick resource books for supporting documentation, the system's CliniGuide feature provides easy to read explanations supporting the suggested codes. Another big plus, according to the hospital, are timely upgrades. For instance, the medical records department recently acquired the Severity Refined DRG calculator. This new feature addresses a new federal regulation which is expected to be introduced in October 1996 by HCFA (Health Care Financing Administration). The new regulation will issue reimbursements according to severity refined DRG; currently, all co-morbid conditions are weighted equally. Thus after the new rule is implemented, coding must reflect the major co-morbid condition. The reasoning behind the new rule is that HCFA will reimburse based on the major existing condition since more hospital resources are being used to treat the condition. Since the upgrade is already in place at Windber Hospital, staff can get accustomed to it prior to implementation -- even though there is not a great deal more for the user to remember when using the new feature. The system does most of the calculations internally.
While Windber Hospital has not conducted a quantifiable study, the medical records department estimates that reimbursements have greatly increased since switching to the new system. This is because they are now sure the diagnosis is being coded accurately all the time, leading to the highest reimbursement level allowable for each case. The time to code a typical patient record has also been reduced by 10%. All told, Windber Hospital has improved accuracy and reduced coding time, and as a result the hospital is getting proper reimbursement for its services.