A Minute for the Medical Staff - Kaleida Health



A Minute for the Medical Staff

A supplement to medical records briefing

December 1999

Personal Financial Profile

PRE$ERVATION

By Robert S. Gold, MD

Vice President

Healthcare Management Advisors

Alpharetta, GA

Competition and cost containment have increased the need for physicians to become aware of the financial implications of their personal practices and of the hospitals to which they admit patients. Medicare’s diagnostic-related groupers (DRGs) have led to considerable data, and other third-party payers use Medicare statistics to evaluate the efficiency of physicians. This data results in your professional profile.

Physicians should familiarize themselves with certain commonly used terms to understand how the coding and reimbursement system works. Doing so will help physicians properly, ethically, and justifiably influence their reimbursement. Here is a brief explanation of some core terms and definitions to get started:

DRGs are groupings of ICD-9 diagnoses that are functionally similar within an organ system. Each DRG has been assigned a relative weight (RW), a comparative severity number that was originally determined as a ratio of utilization statistics from all Medicare billings.

The relative weight of a diagnosis gets multiplied by a dollar amount that equates to the number of dollars a hospital gets for a relative weight of 1.000. This is called the Base Rate.

The average of the relative weights of your patients over a period of time is called your case mix index (CMI). This CMI reflects an estimate of the severity of illness (based on years of statistics of billings) that a hospital or physician or group is dealing with.

To calculate a physician’s efficiency, you can look at the cost per patient divided by the CMI of that group of patients time the base rate.

For example, if a physician had one patient under consideration with a RW (ideally) of 1.000 and the cost was $4,000 for the hospitalization and the base rate was $4,000 for his or her institution, then the efficiency would work out to be 1.

(Cost/Patient)

Divided by = 1

(CMI x Blended Rate)

A physician can influence the CMI by proper documentation of the true severity of illness for his or her patients, and can influence the cost by management of length of stay and utilization of resources during that stay. I will discuss the first of these factors in this issue.

Influencing Factors of Severity

The following elements can make a difference in the assignment of DRG and the RW that it carries:

• Use the history of present illness to describe the clinical picture with which the patient presents so that others who read the chart can get a clear picture of what you had available for your initial assessment.

• Describe the physical findings—all abnormalities noted. If you know that there is a part of the exam that should be done but you cannot do it right now, use the term “deferred,” but later complete that portion of the exam.

• List the chronic, stable conditions that the patient has and is being treated for but that may not be active right at the moment, such as the following:

- COPD, stable - Atrial fibrillation

- CHF, stable - Chronic respiratory failure

- Angina, stable - Diabetes, Type 1 or Type 2

- Seizure disorder - Chronic renal failure

• List additional diagnoses that are active but may not be the reason for admission, such as:

- Decubitus ulcer - Malnutrition

- Gangrene - Alcohol or drug

- Dehydration dependence

• Come to conclusions as to the diagnoses if you can. Give a name to the presenting symptomatology after a day, if not earlier—use “likely” or “probable” or “possible” if you are still in workup mode. Don’t leave the chart with only symptoms to define the reasons for the hospitalization. This tends to imply less use of evaluative and cognitive work on your part.

• List the diagnostic entities that appear while in the hospital under treatment, whether confirmed or suspected:

-Post-op atelectasis -Acute gastric dilatation

-Acute urinary retention -Acute respiratory failure

-Post-traumatic -Volume overload

hemorrhagic anemia -Acute renal failure

• Get credit for your thought processes. Discussing pathophysiologic considerations of the diseases with which you deal augments the work you do and may better describe the severity of illness.

Take, for example, a patient with angina. If you know or suspect that the angina is due to coronary artery disease, then state so in your documentation. If your workup reveals that the angina is due to hypertrophic cardiomyopathy or pulmonary hypertension or aortic stenosis or coronary spasm, mention that instead.

Regardless of the disease process that limits the effective perfusion of the coronaries on a chronic basis, there may be an acute event that precipitates an attack that is not controlled easily with nitrates alone. For example, an anemic patient with chronic renal failure (inadequate hemoglobin delivery to the heart muscle) or atrial fibrillation with rapid ventricular response (decreased pulse pressure) will need control of all these conditions. The more work you do to evaluation the pathophysiology, the higher the level of reimbursement, both to the hospital and to you.

Medical necessity

You should use progress notes to describe the continued need for hospitalization. If the notes say “doing well” or “no change,” ther is no substance for billing or utilization. Describe the progress of each entity that led to the admission. When patients have stabilized, state that they have, but do not lose the condition in your problem list. Give a name to new conditions and carry on with these diagnoses and their progress. Every time you add a medication or change a medication or order a test, write down the diagnostic entity that led to that order.

All payers are looking for documentation of medical necessity to validate the patient’s continued stay in the hospital. As long as the physician uses the history and physcial and progress notes appropriately, the documentation will take care of itself.

And the major elements to accomplish this task include writing about the disease processes that are getting better but are not yet good enough for discharge and writing about the ones that have developed since hospitalization and need further work. Utilization reviewers have tools such as “intensity of service” and “severity of illness” criteria that can help.

A Minute for the Medical Staff is an exclusive service for subscribers to Medical Records Briefing.

Reproduction of A Minute for the Medical Staff within the subscriber’s institution is encouraged.

Reproduction of any form outside the subscriber’s institution is forbidden without prior written permission.

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