317.432.2309
Client Profile:
A growing health system with 3 acute care hospitals, 4 critical access hospitals and 36 provider clinics. The flagship hospital is a 500+ bed, level II trauma center with specialty hospitals for psychiatric care and orthopedic care.
It has a nationally top rated cardiology program that performs cutting edge cardiovascular procedures within the region. The health system has a 19 county service area with multiple rural health entities.
Case Study Challenge:
- Coding and CDI teams were not collaborating or functioning as a cohesive team.
- Provider documentation was not creating an accurate picture of patient acuity
- DRG validation vendor was not meeting the needs of the organization
- No formal commercial DRG denials program had been established
- The health system was receiving subpar quality scores related to documentation and coding issues
Action:
Joint education sessions were developed for our Coding and CDI teams to insure everyone received like information. Additionally, discussion was encouraged between coders and CDI regarding DRG miss-matches and DRG downgrades.
A robust provider education program was developed that consisted of face-to-face individual and group education sessions, in addition to developing relationships with key physician champions that would help facilitate the needed changes.
A DRG validation vendor was recruited that met the needs of the organization. They provided extensive reporting of ROI, query responses, and education opportunities. They developed tailored education for the coding and CDI staff based on findings.
All of these factors helped to paint a true picture of the acuity of our patients and increased our CMI. A better working relationship with the Quality Department was developed, which in turn helped to increase the quality scores and reduce penalties.
A commercial denials program was built and developed from the ground up, and has helped the facility to dispute erroneous DRG denials and prevent payments from being recouped.
Results:
Progress was directly attributed to process improvements and building a collaborative relationship between the coding and CDI teams of the organization. The result was a CMI – Medicare improvement of 1.811 (2015) to 2.120 (2022).
Additionally, the HAC penalty decreased from 0.1 to 0, the DRG validation vendor lifetime ROI increased to 4.22:1, and the Commercial Denials Team successfully appealed $120,000 in fewer than 6 months.