Patient Severity in the Cath Lab: How are payments affected?

Since 1983, hospitals have been paid for inpatient services based on a DRG (Diagnosis Related Group) assignment that classifies the procedure performed or treatment delivered. Each year, the Centers for Medicare and Medicaid Services (CMS) update the inpatient DRG payment system to better reflect the economy and patient conditions. Since adoption of the DRG system, multiple modifications to the payment structure have been made, but none as dramatic as the move to the Medical Severity Diagnosis Related Groups (MS-DRGs), adopted October 1, 2007. This approach was designed to better capture severity levels in patients and gradually begin the move to a cost-based (rather than charge-based) structure. CMS will continue to refine the MS-DRGs and cost-based payment system for the upcoming fiscal year, starting October 1, 2008. Although more accurate, the current and future (October 08 – September 09) payment method requires more resources to capture the most accurate patient severity level, including thorough training and education for physicians, clinicians and coders. We recommend that hospitals make every effort to accurately capture patient severity through complete documentation in the medical record — the more severe the condition, the higher the reimbursement. Incorrect coding can result in lost revenues if processes aren’t closely monitored. Using additional diagnosis codes, CMS has identified three hierarchical complication and co-morbidity subgroups to enhance their ability to identify and reimburse hospitals that treat patients with higher levels of severity. These subgroups are: 1) With Major Complications/Co-morbidities (W MCC) 2) With Complications/Co- morbidities (W CC) 3) Without Complications/Co-morbidities (W/O CC/MCC) To design the medical severity system, CMS looked at fiscal year 2006 data to compare the traditional DRGs to the new MS-DRGs. Table 1 reflects an overall analysis of CMS’s prediction of aggregated DRG splits across severity levels. Since the majority of predicted cases are falling into the lowest-paying severity level, correct and thorough documentation and coding is essential in order to get reimbursed for the higher-paying severity level when warranted. Table 2, based on data from one of Corazon’s clients, illustrates how the severity levels for coronary interventions (with drug-eluting stents or bare-metal stents) have compared to the CMS FY08 prediction above. Even though there were no major discoveries in this case study, it follows the CMS prediction, given the secondary diagnosis codes that drive cases to higher-weighted DRGs are narrower and require appropriate documentation to achieve maximum payment. In terms of reimbursement, Figure 1 demonstrates the FY2008 and proposed FY2009 payment comparisons for each PCI MS-DRG. Figure 1 exemplifies that all DRGs without a MCC (DRGs 247 and 249) are decreasing in reimbursement and all DRGs with a MCC (DRGs 246 and 248) are increasing. Again, this reinforces the need to always capture severity levels. PCI DRGs are a bit unusual, as they are not split solely on severity diagnoses. Cases can fall into the higher-paying DRG if the patient received four or more stents. Keeping in mind the national average number of stents is 1.4 per case, we believe that a robust quality oversight process should evaluate patient selection and judgment related to all cases that require four or more stents. In addition to this quality oversight process, programs should assess whether the difference in payment covers the supply cost of the additional stents. Assuring that documentation reflects patient severity is key; however, recognizing the increase of associated resources needed to care for a more complex patient is equally important to program success. For example, it has been common practice for physicians to document “CHF,” or congestive heart failure, on the medical record. In the past, documentation of “CHF” would result in the higher-paying DRG, but now more specific diagnoses, such as “Chronic Systolic Heart Failure,” are needed. Troubleshooting of the documentation and coding process needs to occur in order to better identify ways to obtain complete and accurate information. The use of non-specific codes undermines these efforts, so the most specific codes applicable should always be documented. Furthermore, physicians must be educated regarding these changes. Both the physicians AND the hospital must work together to implement new systems and oversight processes. Other recommendations to assure appropriate reimbursement include: • Focus on detailed and accurate documentation, better information on the incidence of disease, and code ALL complications and co-morbidities. Don’t stop at one code that qualifies for a higher-paying DRG; make sure to code all secondary diagnoses, which can increase the case mix index. • Move the coding query and clarification process from the back end to the front end. Most of the oversight for the documentation and coding process occurs after the patient is discharged. Consider options to move this to the front end by working with case management to clarify documentation prior to discharge. This approach will help with the coding turnaround time and physicians will find the process less frustrating because the patient is still at the top of their mind. • Modify forms, such as pre-procedure forms and progress notes, to create pick-lists that give options for the physician to capture patient information in a standardized format. Be careful not to prompt the physician for a specific code, especially if that code will result in a higher severity level. • Consider having a third party to audit and monitor processes and make recommendations. Limiting the scope of services to be evaluated, such as diagnostic caths, coronary interventions, etc., can result in a focused effort to create and sustain change. Corazon has developed CORE (Corazon Operational and Revenue Evaluation), which pairs an operations assessment with an audit of coding and documentation practice as a way for clients to evaluate their performance. • Manage operating costs and length of stay. Program margins erode every additional day over the geometric mean length of stay set by CMS. A cost reporting system can be used to review each case category (e.g., Cath, PCI, Vascular, and Electrophysiology) and the MS-DRG split on a regular basis to track and trend changes. Such a process will allow programs to identify which costs are increasing or deceasing, investigate why, and then develop plans to address them. As CMS takes steps to further revise the MS-DRG payment system and readjust severity levels, hospitals must quickly react and adapt to a more intense reimbursement structure. Although implications of the MS-DRGs will be across the full spectrum of acute care, we believe that organizations must be particularly vigilant for cardiac cases, which typically are resource-intense with high-cost devices and complex patient conditions. Cardiovascular programs must work now to strategize and create action plans to aggressively identify severity levels to reflect the most accurate payments, especially as future changes are expected. Kristin is a Consultant with Corazon, offering consulting, management resources and recruitment for the full spectrum of cardiovascular services. Call (412) 364-8200 or visit www.corazoninc.com for more information. To reach Kristin, email kturkovich@corazoninc.com.

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