Expert System Helps Increase Reimbursements While Cutting Down Coding Time at County Hospital
By Scott Campbell,
RRA, CPUR, CPHQ
Director, Medical Records/Quality Improvement
Ward Memorial Hospital
Monahans, Texas
Ward Memorial Hospital received $51,000 more in Medicare/Medicaid reimbursements by coding diagnosis related groupings (DRG) with a computer. An expert software system replaced hand coding methods and guides the user to select a more precise diagnosis as substantiated by the medical records.
As an example, a patient was recently diagnosed as having pneumonia, organism unspecified. The system noted that a secondary diagnosis of emphysema is common with such a principal diagnosis. After reexamining the patient record in more detail, the coder found that the patient did in fact display emphysema symptoms. In this case alone the organization increased reimbursement by $1700. In another instance, when entering data on a recent female patient the principal diagnosis was coded correctly as disorder of menstruation. When the system stored the principal diagnosis, it noted that abnormal bleeding complications often occur with disorder of menstruation and would yield a higher reimbursement if present. The flag caused the coder to examine the patient's full record. Although the secondary diagnosis was not mentioned by the physician, it was mentioned in the nursing notes. The coder discussed the case with the physician who realized the secondary diagnosis had been overlooked in his notes. This information increased this reimbursement by over $1000.
Ward Memorial is a 49-bed county hospital. Patients using Medicare make up 46 percent of the patient base, and those using Medicaid constitute about 32 percent. The current system of Medicare reimbursements bases its payments strictly on the diagnosis to which the patient's stay is grouped or assigned. Most large third party payers have also adopted the grouping system. Up until a year and a half ago, a small staff did all the hospital's coding by hand. To begin the process, coding staff searched the lengthy index in the ICD-9-CM manual for a diagnosis. The reference manual used by the hospital was DRG Working Guidebook from St. Anthony's Publishing. If the terminology on a patient record did not match the manual's, they were referred to another section. Many times, staff looked through several different pages and categories, often being directed to additional references. The coder would typically make an educated guess as to the primary and secondary diagnostic codes and then enter them into a customized commercial hospital information system.
Coding is a very tedious job, which means that coders sometimes get tired and transpose digits or make other mistakes. When coders became tired they were also prone to settle for the first available diagnosis rather than optimizing. The codes were accepted exactly as they were entered without any error-checking or optimization. Errors sometimes occurred during transfer to the financial side of the system. For example, sometimes when a series of three or four ICD-9 codes were entered, the system would drop the last code. It was easy to make mistakes and not get the right codes for a diagnosis, or to miss that a more specific diagnosis was needed. Since coding staff turnover was higher than the hospital desired, valuable staff time was taken up training new staff members using the cumbersome books. The result was that the hospital did not always get as much reimbursement as it was entitled to, or it had to send money back when payments were made in error. The manual methods also meant that it required a great effort to monitor the performance of coding staff.
The department director had worked in other health care facilities using computer coding techniques and knew the limitations of hand coding could be eliminated. Thus, in hopes of improving its coding accuracy, the hospital investigated Clinical Coding Expert software from IRP Systems, Wilmington, Massachusetts -- a DRG encoder that incorporates the entire ICD-9-CM and CPT-4 coding book on a computer. A secondary goal was to decrease the time spent coding. The developer of the software offered the hospital a one-month trial during which it could use the system with no strings attached to determine whether reimbursements would increase. During this month, the hospital ran both the old and new systems in parallel and compared the results at the end of the trial period. The reimbursements with the new system improved by $1700. This figure was substantially greater than the cost of the system at $399 per month. This included a personal computer with enough hard disk space to handle many other applications, printer and all required supplies. It's also important to note that much of this first month was spent in a training mode. Hospital management felt confident that they would be able to significantly improve the level of reimbursements in subsequent months as users become more experienced. Thus the decision was made to enter the lease arrangement.
Clinical Coding Expert greatly simplifies the coding process. The user begins by entering identifying information such as the patient's age, date of admission, date of discharge, etc. The DRG identification process begins (in most cases) by selecting diagnostic terms from the record; entering them in the Encoding 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.
Working by hand, the principal diagnosis itself is sometimes so difficult to determine that there is a great temptation to stop there. Clinical Coding Expert clearly demonstrates, on one screen, possible alternative DRG assignments. This assists the coder to review records to see if a secondary diagnosis, with a higher DRG reimbursement, could actually be the principal diagnosis. The user is reminded that no complications have yet been entered, and the software then checks 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. In most cases, the physicians themselves do not correctly identify all of the complications for a particular patient but the information is usually there on the chart. Sometimes a diagnosis will be made but not even entered on the chart, requiring a bit of detective work.
The departmental director has also designed and implemented performance improvement projects with Clinical Coding Expert. Management checks coding accuracy by examining a chart assembled using the encoder and matching it against the same chart encoded by hand. They search for inaccurate diagnoses and procedures, or any missing information. Spot checks over the last few months show virtually no inaccuracies. Since Ward Memorial Hospital chose to lease the system with a printer and a laptop computer, staff can perform an initial DRG assignment on the floor of the hospital. The admitting diagnosis is entered, along with any procedures that have been done, and this information yields a DRG number and average length of stay. This information can be given to the doctor for planning purposes.
Clinical Coding Expert is an expert system containing 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 needed 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 that 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.
For the first 11 months of using the new system, Ward Memorial Hospital tracked coding using both manual methods and the computerized system. During that time they were reimbursed $51,000 greater than they could have received using manual techniques. This represented a 7% increase in the hospital's total reimbursements. In order to achieve that same amount, it would have required many more staff people, more training, and more books. Although it is difficult to quantify an exact time savings since switching to DRG, there is no doubt that staff now has faster access to the information that once took many steps to retrieve. Training time is no longer an expensive proposition. It takes about one day to train someone to use the software. Thus, by improving accuracy and reducing coding time, the hospital now receives proper reimbursement for its services.