Hospital Integrates DRG Coding and Optimization with Information System
By JoAnne Kerwin
Director, Health Information and Record Services
Louis A. Weiss Memorial Hospital
Louis A. Weiss Memorial Hospital has increased reimbursements and coding productivity by integrating a DRG encoder and optimizer with its hospital information system. Coders can now simply hit a hotkey from their clinical abstracting screen to enter the encoder. All relevant information is transferred from the clinical abstracting screen to the encoder, including whether the patient is on Medicare or Medicaid. The encoding software provides ICD-9 and CPT-4 codes and assists the coder towards the optimal DRG. When this process is completed, the coder hits another hotkey and the diagnoses and procedures are automatically transferred back to the clinical abstracting screen.
Louis A. Weiss Memorial Hospital is a 200 bed teaching hospital affiliated with the University of Chicago Hospitals. The hospital's specialties include cardiology, oncology, gastroenterology, and urology. In the past, the coders used manual code books and a computerized grouper. The grouper had minimal optimization capabilities. This tool offered satisfactory performance, but during the process of installing a new hospital information system it became clear that the two packages were not compatible. This was discovered shortly before the hospital information system went live, leaving very little time to find an alternative. The problem was complicated by the fact that monies had not been budgeted for an encoder/grouper and most of the coding products that were available cost a considerable amount. There simply wasn't time available to justify a high-priced program. This made it essential to find a low cost alternative.
At about this time, the coding supervisor remembered Clinical Coding Expert from IRP Systems, Wilmington, Massachusetts. This program includes an encoder DRG grouper that incorporates the entire ICD-9-CM and CPT-4 coding book on a computer and costs considerably less than other alternatives. Our monthly rental fee includes an unlimited user network license, toll-free support, training, and all updates. The price was very attractive and the program includes optimization capability that had not been offered by the previous grouper. Another factor in its favor was that it is user-friendly, making it relatively easy to learn. The program uses a series of hierarchical menus that guide the user to the proper diagnosis. However, experienced coders are able to use the product as they would their coding books. IRP was able to customize the system to take into account the unique aspects of Illinois Medicaid reimbursements.
Jennifer Aron, Systems Analyst at Weiss at this time, oversaw the process of integrating the encoder with the hospital information system. Programming was headed up by Doug Maskill of Healthcare Systems Integration. The encoder/optimizer runs on the file server so that it can be easily accessed by four coders and one supervisor. This simplifies the installation of updates because they only have to be loaded on a single computer. The Shared Medical Systems INVISION hospital information system is used to provide coders access to patient account records. The coder calls up the appropriate patient account record, extracts pertinent information from the medical record, and moves to the last screen that covers diagnoses and procedures. Here, the coder hits an escape sequence. This starts an IRP session that reads this file and provides all the pertinent information to perform the optimization.
Patient information such as the name, age, admit date, discharge date, and length of stay are automatically transferred over into the encoder. The coder then determines whether this is a Medicare or Medicaid case. This automatically triggers the encoder to reflect the proper DRG grouping criteria. The coder then codes the chart using the encoder. Reference books are still used in some cases primarily by the coders that are less comfortable with the computerized approach. The DRG identification process begins (in most cases) by selecting diagnoses from the record; entering them in the coding system; and then using the menu. The process continues through a hierarchical series of menus until the user zeroes in on the precise diagnosis. Once they reach the proper diagnosis, they push a hot key and the computer provides the proper code.
This system guides the coder to select a more precise diagnosis as substantiated by the medical record documentation and frequently results in a higher reimbursement level than if the simpler alternative was selected manually. But the real power of the system comes in its ability to help identify complications. Working manually, complications and cormorbidities (C/Cs) may be difficult to determine. The software clearly demonstrates on one screen possible C/Cs. This assists the coder in reviewing the record to see if one of these complications or cormorbidities exist. By adding substantiated C/Cs, a higher paying DRG may be realized. The software also simplifies the process of selecting complications by reminding the user that no complications have yet been entered, determining whether each item entered qualifies as a complication and suggesting possibilities.
When they have finished, the coder hits a hotkey that returns them to the hospital information system. The coder gets a message box that asks if they want to enter the information into SMS. If they enter yes, the data is posted to the patient account record. If the answer is no, the data is saved in a file and the user goes back to the SMS abstracting screen. The final step is hitting a single key and diagnosis and procedure codes are sent to billing. A bill is then generated in the billing office. The result has been a substantial increase in coding productivity. Patient volume, particularly outpatients, has increased since the system was installed yet the number of hours devoted to coding has been reduced. Reimbursements have also improved due to the optimization procedures.