Rural Hospital Utilizes an Affordable Method to Generate Accurate Medicare Reimbursements
by Twila Weiszbrod
Medical Records Director
East Adams Rural Hospital
Ritzville, Washington
East Adams Rural Hospital is a 20 bed hospital in a town with a population of less than 2000. The elderly constitute a very high proportion of the population of our service area which means our patients tend to be quite ill and stay for a long time. The current system of Medicare reimbursements, on the other hand, bases its payments strictly on the diagnosis related group (DRG) to which the patient's stay is grouped or assigned. Most large third party payers have also adopted the DRG system in the state of Washington. As a result, our reimbursements frequently do not cover the cost of patient care. Further difficulties are generated by the fact that our sickest patients are frequently transferred to larger hospitals in Spokane. This normally means the Spokane hospital gets the major portion of the reimbursement because their DRG assignment is based on the procedures performed and the larger hospital naturally is able to perform more procedures. When I joined this hospital, these difficulties were compounded by turnover in the records department and a manual billing system whose efficiency left much to be desired. I found that in many cases, we were receiving much less even than the meager reimbursement we were entitled. I didn't have enough time in the day to make our manual system work so I began investigating computerized alternatives.
I found the latest generation of computerized coding systems can greatly increase reimbursements by helping to identify overlooked diagnoses. The system I selected, called Clinical Coding Expert from IRP Systems, Wilmington, Massachusetts, includes a DRG encoder which incorporates the entire ICD-9-CM and CPT-4 coding book on a computer. This 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. But the real power of the system comes in its ability to help identify complications. Working by hand, the principal diagnosis itself is 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 software greatly 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. In many cases, these complications are items the person doing the coding manually may not consider. For example, we had a man admitted with pneumonia. He also had diabetes mellitus type II. This seemed like it would be a complication. I was surprised to find that it did not qualify. So, I entered the next item on the chart -- low sodium -- and found it did. Without the aid of the program, I would have never guessed low sodium would qualify as a complication/comorbidity when occurring with the principal diagnosis. 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. For example, now that I am aware a urinary tract infection is considered a complication with many principal diagnoses I keep an eye on the lab results. Oftentimes, a patient who is in the hospital for something else will be shown through a urine culture to have an infection. The patient will be treated with antibiotics but the diagnosis will never be entered explicitly on the chart.
Let's look at a few more examples. A man was admitted with pneumonia. I entered the principal diagnosis and the program noted no complications had been entered. I looked at the chart and noticed the patient was an alcoholic. I entered that into the program and found it was a legitimate complication. Another patient was admitted because of injuries to the face, neck and trunk suffered in an automobile accident. There were a number of secondary injuries but as I entered each I noted they were not considered to be complications. Finally, I entered the fact that the patient had blood in her urine. That turned out to be a complication. The chances are, if I was coding by hand, I never would have thought to enter that. The effectiveness of this technique is easy to measure because a few months prior to purchasing the software I hired a company to review our Medicare charts. Their business is attempting to enhance the DRG reimbursement and they are compensated by receiving a percentage of the additional reimbursements they find. The first several months they earned a considerable fee. As I became proficient at using the software, however, their findings were quickly reduced. In the last six months, when I have become fully experienced, they have not found a single item.
The information entered into the program can be used in a variety of different ways. We have a clinic all of our providers work in. In the early stages of using the program, I would handwrite the diagnosis onto a list of patients for use by the billing department. Later, IRP explained how I could use a hotkey to go into the Wordperfect word processing program and automatically enter the DRG next to the patient's name. Thus, the same document produced by the coder with a little additional effort can be converted into a document used for hospital billing. The same list is also useful as a patient census and can be printed out and kept in a logbook to serve as the outpatient log.
Use of the system for Concurrent Review is an important point. Usually while a patient is in the hospital I will do a concurrent review of the chart. I determine the principal diagnosis and note that the mean length of stay for that diagnosis is 4 days. On day three I will notify the doctor of that fact and ask whether the patient is ready to be discharged. In cases where a patient has two major diagnoses either of which could be considered the principal diagnosis, the program makes it easy to determine which provides the longer average length of stay.
At first I ran into some resistance from physicians who were concerned these techniques would interfere with the diagnostic process. A few of them were concerned that if they were aware of the reimbursement levels for different diagnoses, it would interfere with the diagnostic process and become unethical. Fortunately, I was supported completely by my administrator. I pointed out the purpose is merely to increase communications and ensure relevant diagnoses are properly reimbursed and the doctor would never know the reimbursement amounts. I showed the doctors the form the program prints out for the physician to indicate whether or not he or she agrees with the principal diagnosis. In the past, physicians generally never even saw a "working" Attestation Statement prior to the patient's discharge.
Now, I put the sheet on the front of the chart and the doctor, when making his or her rounds, sees it and either signs it or writes a note stating why they disagree. There have been times when I have gone back three or four times in order to ensure the proper diagnosis was determined. This interactive process was something that never existed with the previous manual system. Now, the doctors all love the program. They understand that when I say that the patient should be reviewed for discharge after four days, it's only a suggestion. They make the final decision. When they say the patient needs to stay an extra day, the patient stays.