Capturing the Activity in Activity based funding

Capturing the Activity in Activity based funding

Activity Based Funding - The National Health Reform Agreement 2011 provided for the introduction of Activity Based Funding from July 1, 2012. - The aim being to work towards a system that would fund Australian public hospitals on activity and away from historical block funded systems. - Hospital functions were grouped into 7 main categories: - Admitted acute - Emergency Services - Non-Admitted - Subacute - Mental Health - Community - Teaching, training and research 2

Allocating a Diagnosis Related Group Administrative data ICD-10-AM and ACHI Codes Diagnosis Related Group Admission and discharge dates Determines length of stay Same day status Patient age Separation mode Admission weight (newborns only) Patient gender (edits only) 3

Funding model DRG Additional data items National Weighted Activity Unit ($) Length of stay Patient address (postcode) Health insurance election Indigenous status Hospital status Other 4

ICD10-AM and ACHI codes Principal Diagnosis code The condition which after study is chiefly responsible for occasioning the admission. Conditions affecting the admission in terms of requiring treatment, evaluation or increased monitoring. Additional diagnoses Diagnosis Related Group Procedure codes 5

Scenario 1a Clinical Record ICD-10-AM AR-DRG V7.0 Principal Diagnosis: Fracture x 2 ribs S22.42 Additional Diagnosis: MDC 04 Diseases & disorders of the Respiratory System Fracture shaft humerus S42.3 Fall from ladder Procedures: Plaster applied to fracture of humerus W11 AR DRG E66C Major chest trauma w/o CC Weight: 0.5332 6

Scenario 1b Clinical Record ICD-10-AM AR-DRG V7.0 Principal Diagnosis: Fracture shaft humerus S42.3 Additional Diagnosis: MDC 08 Diseases & disorders of the Musculoskeletal system and connective tissue Fracture ribs x 2 S22.42 Fall from ladder Procedures: Plaster applied to fracture of humerus W11 AR DRG I75A Injuries to shoulder, arm, elbow, knee and ankle with CC Weight: 1.8768 7

Scenario 2a Clinical Record ICD-10-AM AR-DRG V7.0 Principal Diagnosis: Atherosclerotic heart disease I25.11 Additional Diagnosis: MDC 05 Diseases & disorders of the Circulatory System Procedures: Coronary bypass graft, LIMA graft 38500-00 [674] Coronary bypass graft, Radial artery 38500-02 [676] Cardiopulmonary bypass 38600-00 [642] General Anaesthesia, ASA 2 92514-29 [1910] AR DRG F06B Coronary Bypass without Invasive Cardiac Investigations without CC Weight: 4.8491 9

Scenario 2b Clinical Record ICD-10-AM AR-DRG V7.0 Principal Diagnosis: Atherosclerotic heart disease I25.11 Additional Diagnosis: MDC 05 Diseases & disorders of the Circulatory System Hypertension I10 Type 2 Diabetes with background retinopathy E11.39 ADD: Pneumonia J18.9 ADD: Acute posthaemorrhagic anaemia Procedures: D62 Coronary bypass graft, LIMA graft 38500-00 [674] AR DRG F06A Coronary Bypass without Invasive Cardiac Investigations with CC Weight: 6.1509 Cardiopulmonary bypass 38600-00 [642] General Anaesthesia, ASA 2 92514-29 [1910] 10

Clinical documentation Clinical documentation is used throughout healthcare to describe care provided to a patient. The purpose of clinical documentation is to communicate essential information between healthcare providers and to maintain a patient medical record. 11

The coding process 1. Clinical documentation 2. Principal Diagnosis, Additional Diagnosis, Procedures 3. ICD-10-AM/ACHI Codes 4. DRG Assignment 5. Reimbursement 12

Getting it right The introduction of ABF funding has provided a considerable incentive for accurate and complete coding but as we have seen the coding can only be as good as the clinical documentation. Many Coding departments have a quality focus and have in place a structure which provides for ongoing education of coders and auditing of episodes to ensure the best coding and thus DRG outcomes for hospitals. As part of this process Coding Departments will also often engage with Clinicians to clarify the documentation. Queries may be required in instances of: 1. ambiguous, incomplete and conflicting documentation. 2. to add specificity to a diagnosis to allow more complete and accurate coding. 3. to enable a Coder to code a condition that is documented but not in a way that is codeable. Often the focus of these queries is to assure the appropriate DRG outcome for the hospital. 13

The challenge Unable to Code Unable to Code Unable to void, will insert Foley Haemodynamically unstable Will rehydrate K = 2.0, will give KCL Chest Xray: Consolidation HgB 5.2, Transfuse BMI 42 Emaciated, Protein/Albumin BMI Able to Code Retention of urine Hypotension, shock Dehydration Hypokalemia Pneumonia Acute Blood Loss Anemia Morbid obesity Severe Protein Calorie Malnutrition

Clinician Bridging the Gap HIM/Coding Professionals Clinician Documentation is received in CLINICAL terms Breakdown between the two separate Languages Documentation for coding, requires specificity in DIAGNOSIS terms

Retrospective review of the documentation 1. Clinicians document in the patient record 2. Discharge summary is generated 3. Patient discharged 4. Medical record sent to coding department Incomplete or ambiguous documentation is traditionally identified at this late stage. 5. Coding takes place 6. Query process Limitations of this process: Information is gathered after the fact. Process is time consuming for both Coders and Clinicians. It is disruptive. Queries are typically driven by DRG outcomes only. Cannot capture missing information 17

Benefits of Concurrent Review Benefits of real time documentation review Queries generated are more appropriately directed to the real time capture of documentation related to the disease process, treatment plans and diagnostic outcomes. They are driven at the level of patient care. Responses to queries are more timely. The treating Clinician is able to recall and document in the medical record on the spot. Documentation is complete at the time of discharge and the episode able to be coded in a timely manner. Greater opportunity for Clinician engagement. The process is continuous and sustainable. Ensures the data collection reflects the activity to support all purposes of the data collection. Concurrent review CDI programs have been running in the US for 20+ years now. This has been shown to increase the Case Mix Index by 2%-4% for non Same Day patients. 18

Case Mix Index A case study Total Case Mix Index Opportunity2.6% 19

Concurrent review of the documentation Clinical Documentation Specialists Clinical Documentation Specialists identify incomplete or ambiguous documentation at Step 1 1. Clinicians document in the patient record 2. Discharge summary is generated 3. Patient discharged 4. Medical record sent to coding department 5. Coding takes place 6. Information used for reporting and reimbursement 20

Bridging the gap Clinicians document using clinical terms Clinical Documentation Specialists Health Information Managers (HIMs) & coders need diagnostic terms for coding. When terms are not present, this affects the DRG and reimbursement Breakdown between the two separate languages 21

Documentation Flow Specific and Complete 1. Clinical documentation 2. Principal Diagnosis, Additional Diagnosis, Procedures 3. ICD-10-AM/ACHI Codes 4. DRG Assignment 5. Reimbursement 24

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Thank you Contact details: Kathy Wilton kwwilton@mmm.com