Teaching physicians: What’s in it for
me (WIIFM)
Margi Brown, RHIA,
CCS, CCS-P, CPC
Objectives

This “what’s in it for me” session will cover how to
get the busiest physician/provider’s attention and
keep it with the goal of accurate documentation in
mind.
Topics of discussion

Establishing the initial contact.

Determining the focus of the presentation(s) and other
efforts.

Compiling numbers that impact the physician.

Providing take-away tools.

Sparking interest in their office setting.

Avoiding potholes on the way .

Ensuring ongoing marketing and feedback .

Taking the next steps: Once they are hooked, then what?
Determine your bottom line

Hospitals and each physician need the most
accurate and specific documentation that
translates into correct and compliant coding to
reflect the true complexity of care and severity of
illness of their patients.
Initial steps

Before initiating any contact with providers …

Common goals

Set responsibility

Common goals

Set game plan:
–
Involvement, staging, calendar
Information likely disseminated through insurance
company’s website
HealthGrades for hospitals
And soon MDs as well,
provided that Consumer
Checkbook wins
its appeals
Physician public profiling
Pay for performance

Definition: Pay for performance (P4P) is a catchphrase
for a management tool that establishes incentives for
clinicians and institutions (e.g., hospitals) to deliver care
that third parties deem is necessary and appropriate to
achieve the highest-quality standards and best
outcomes.

Current Metrics:
– Process-oriented activities

–
Infrastructure improvements

–
Core Measures, Physician Quality Reporting Initiative (PQRI)
Principally information technology—CPOE
Patient outcomes

Risk-adjusted mortality
P4P goal: Increase value



Defined as outcomes (quality) ÷ Cost
–
Cost is easy to identify
–
Outcomes (quality) is not.
 The degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are
consistent with current professional knowledge.
Discernment – What do we measure?
–
Process functions? (e.g., door-to-wire time)
–
Death? –Was it expected or unexpected?
–
Complication rates? –What is preventable and what is not?
–
Functional outcome?
–
Patient satisfaction?
Dissemination
–
How to we communicate our results to our constituency?
Goals for both

Physicians:
–
Encourage physicians to deliver their ethical obligation to practice
evidence-based medicine while better allocating resources
–
More proximal to the medical decision-making


–

Power of the pen
Power of the knife
Leverage with hospitals is professional relationships or to move their
practice to a competitor
Hospitals:
–
Better develop systems and support

–
Less proximal but still critical
Leverage with physicians is professional relationships or medical staff
credentialing.


Relationships – “Win-Win” between physician and facility
Credentialing–like firing a poor-performing employee
Physician reimbursement
“Tier and Steer” networks

Three proposed office
visit tiers based on cost
and “quality of care” by
physician:
–
–
–
$15/10% co-payment for
tier 1 MD
$30/20% co-payment for
tier 2 MD
$45/30% co-payment for
tier 3 MD
Physician profiling example—Blue
Cross of Texas
No changes—still measurable …

Where do you fall in the “bell” curve ?
or
OBS vs. inpatient—matching?
Observation




Initial OBS day (3/3):
99218 –99220
Same DOS for
admit/disch (3/3):
99234-99236
Inpatient

Admit, H&P (3/3):
99223

Same DOS for
admit/disch (3/3):
99234-99236

Subsequent day (2/3):
99231-99233

Disch: 99238 - < 30
minutes & 99239 - > 30
minutes
Disch: 99217
“Extra” days (2/3):
99211-99215 (per
CMS)
99221-
Complexity of medical
decision-making

Refers to the complexity of establishing a
diagnosis and/or selecting a management option
as measured by the following:
–
–
–
Number of possible diagnoses
and/or management options
Amount and/or complexity of data
Risk to the patient
Complexity of medical
decision-making
Determined by (1) Number of diagnoses or treatment options, (2) Amount
and/or complexity of data reviewed, and (3) Risks of complications and/or
morbidity or mortality
1. Number of Diagnoses or Treatment Options
A
B
C
D
Problem(s) Status
Number
Points
Results
max=2
1
Self limited/minor
Established problem to examiner … stable/improved
1
Established problem to examiner … WORSENING
2
New problem to examiner w/no additional workup planned
max=1
New problem to examiner w/additional workup planned
3
4
TOTAL:
Risk of significant complications,
morbidity and/or mortality

For E/M: The risk to the patient is based upon
the highest level of risk associated with the:
–
–
–
Presenting problem(s)
Diagnostic procedure(s)
Possible management options
Explain the data source

For both hospitals and physicians:
–
–
–
–
Documentation is the bottom line for both, leading
to the translation process of narrative diagnoses
and procedures to numbers –codes
Comparison of ICD-9-CM and CPT/HCPCS
systems
“Severity adjustment”
Mortality and morbidity rates
Hospital—IPPS—Inpatient Prospective
Payment System methodology
One set payment to the hospital is determined by
assignment:
Of codes for all (documented) diagnoses and procedures
To one Major Diagnostic Category (MDC)
Then further to one MS-DRG
All statistics are based on billed case-mix index (CMI)
Daily notes
Why is the patient
here today?

Who?

What?
Each note must:

Where?
 Support what is

When?
 Stand alone

How?
 Be legible
Why?
 Show medical

coded and billed
necessity
Medical necessity and the
correct level

"Medical necessity of a service is the overarching
criterion for payment in addition to the individual
requirements of a CPT code.

It would not be medically necessary or appropriate to bill
a higher level of evaluation and management service
when a lower level of service is warranted.

The volume of documentation should not be the primary
influence upon which a specific level of service is billed.
Documentation should support the level of service
reported.“

(CMS Claims Processing Manual (Publication 100-04),
Chapter 12, Section 30.6.1 - Selection of Level of
Evaluation and Management Service).
Reimbursement factor—RW

RW (Relative Weight)—Weighted number
assignment

Hospital: This number is assigned to each MSDRG. The assigned weight is intended to reflect
relative resource consumption associated with
each DRG.

Physician: This number is assigned to each
CPT/HCPCS code.
CMI and the provider

Low CMI = low “severity” low “quality”?

High CMI = high expected cost & LOS?
– My patient’s are sicker.

Measurement of high cost with low CMI = loss for patient,
insurance company, hospital, and physician?
(contracts?)


Credentialing, pay for performance – how does the
physician rate?
Complete picture of quality, core measures, resource
consumption, LOS, cost, compliance, audit risk, and
much more.
Analyze the stats













Dr. 1 1.03
Dr. 2 0.96
Dr. 3 1.11
Dr. 4 1.07
Dr. 5 1.03
Dr. 6 1.05
Dr. 7 1.10
Dr. 8 1.17
Dr. 9 1.05
Dr. 10 1.04
Dr. 11 1.03
Dr. 12 0.95
Range = 0.95 – 1.17

If Medicare Reimbursement for
case mix of 1.0 = $4500 per
patient
–
–
–
–
–
Low = 4275
High = 5265
most likely to risk RAC?
best mortality adjusted data?
discharge patients with more
symptom diagnosis? (chest pain,
syncope, AMS…)
Analyze the stats

Doctor 1
1.28

Doctor 2
0.81

Doctor 3
1.15

Doctor 4
1.42

Doctor 5
1.09

Pulmonary /Critical
Care


If Medicare reimbursement for
case mix of 1.0 = $4500 per
patient
–
–
–
–
–
Range: 0.81 – 1.42
–
Low = 3645
High = 6390
Have illegible handwriting?
Show the most resistance to coding
queries?
Will have the highest mortality (risk
adjusted)?
Are most likely to have his/her data
published in the newspaper
PD—Principal diagnosis

Coding guideline for inpatient hospital cases

Principal diagnosis
–
"that condition established after study to be
chiefly responsible for occasioning the admission
of the patient to the hospital for care.“
The principal and the why’s
Acute
Could not
be treated as
outpatient
Meets admit
criteria
Acutely
treated
Aggressively
Managed
Principal Diagnosis
Secondary diagnoses and other

Comorbidity:
– A pre-existing condition that affects the treatment received or the
length of stay

Complication:
– A condition that arises during the hospital stay that affects the
treatment received or the length of stay

MCC or CC

Data integrity

Medical necessity

Where do you draw the line?

Discharge status

When does it count?
Example of vagueness

Provide real-life samples

Now ask: What was their billing for the
physician?
–
–
–
–
Critical care?
Level: 9923_: 1,2, or 3?
Medical necessity
Link back to their bell curve, their stats, and
compare to the hospital stats
POA defined

POA—Present on Admission purpose
–
–
To differentiate between conditions present on
admission and conditions that developed during
an inpatient admission.
The focus is to assess the timing of when the
condition presented.

Pre-existing or hospital-acquired?
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HAC –Yes or no, and why?
Indicator
Definition
Yes; POA
Will assign to higher
weighted DRG
No; Not POA
Will NOT assign to higher
weighted DRG
Unknown: insufficient
documentation
Will NOT assign to higher
weighted DRG
Clinically Undetermined:
Unable to determine based on
clinical picture.
Will assign to higher
weighted DRG
Y
N
U
W
How a HAC will be treated
with this indicator
Liability implications

Were prevention guidelines followed?

Public reporting of infections, hospital-acquired
conditions (HACs).

MD-specific data on HACs.

Increase in lawsuits against hospitals/MDs.

Some HACs or infections are expected.

How can hospitals/MDs defend against HACs?
Provider defined for POA

“Medical record documentation from any provider (a
physician or any qualified healthcare practitioner who is
legally accountable for establishing the patient’s
diagnosis) involved in the patient’s care and treatment
may be used to support the determination of whether a
condition was present on admission or not; and the
importance of consistent, complete documentation in the
medical record cannot be overemphasized”
MLN Matters number: MM5499 Related Change Request Number: 5499,
091107 update and Transmittal #289 071707 update
Joint effort

“Finally, you should keep in mind that
achieving complete and accurate
documentation, code assignment, and
reporting of diagnoses and procedures
requires a joint effort between the
healthcare provider and the coder.”
MLN Matters number: MM5499 Related Change Request
Number: 5499, 091107 update and Transmittal #289
071707 update
National top 10 list
Top Ten
2007 RW
127 Heart Failure
1.0490
89 Simple Pneumonia with CC
1.0376
544 Major Join Replacement or Attachment
1.9878
88 Chronic Obstructive Pulmonary Disease
0.8878
576 Septicemia w/o Vent > 96 Hours
1.5996
182 Esophagitis, Gastroenteritis, etc with CC
0.7853
14 Stroke
1.2118
174 Gastrointestinal Hemorrhage with CC
1.0296
316 Renal Failure
1.2602
320 Urinary Tract Infection
0.8769
291
292
293
193
194
195
469
470
190
191
192
871
872
391
2008/2009 MS-DRG(s)
w MCC: 1.2585 / 1.4465
w CC: 1.0134 / 1.0069
w/o: 0.8765 / 0.7220
w MCC: 1.2505 / 1.4327
w CC: 1.0235 / 1.0056
w/o: 0.8398 / 0.7316
w MCC: 2.6664 / 3.2901
w/o MCC: 1.9871 / 2.0077
w MCC: 1.1138 / 1.3030
w CC: 0.9404 / 0.9757
w/o: 0.8145 / 0.7254
w MCC: 1.7484 / 1.8222
w/o MCC: 1.3783 / 1.1209
w MCC: 0.9565 / 1.0856
392 w/o MCC: 0.7121 / 0.6703
64 w MCC: 1.5470 / 1.8450
65 w CC: 1.1901 / 1.1760
66 w/o: 1.0303 / 0.8439
377 w MCC: 1.3367 / 1.6073
378 w CC: 1.0195 / 1.0043
379 w/o: 0.8476 / 0.7565
682 w MCC: 1.4664 / 1.6403
683 w CC: 1.1942 / 1.1304
684 w/o: 0.9835 / 0.7305
689 w MCC: 1.0587 / 1.2301
690 w/o MCC: 0.8000 / 0.7581
What do you mean?

Low H/H
Insufficiency/distress
Infiltrate
Hypotension

Symptom, sign, or 







AMS, weakness, chest pain, …
Contradiction (attending vs.
consultant) or terms
Lab/radiology/path
finding
Acuity

Anemia … due to-

Failure

Pneumonia or CHF

Shock. ? Type, ? other

Due to, Link, Diagnosis/disease

Clear and concise

Clinical significance

Acute, chronic, acute on
chronic
Provide examples of inference





“Clinically” or “reasonably” vs. actual documentation
Meaning? Interpretations differ?
CMS to set the policy:
– Determinations are “inconsistent”
– Error rate is “compromised”
“lack of understanding documentation requirements”
Disservice by “under-documenting”
– Continuity of pt care, severity, LOS, resources
– Patient – prevent from obtaining necessary services?
 Increased and inaccurate out of pocket costs?
Call it what it is

Obesity
–
Morbid obesity

Delirium

Sepsis vs. urosepsis

(VAP)—“Ventilator associated pneumonia”
specifically documented by the physician

Hypoxia

“Acute” exacerbation …
Heart failure weighted
Did the decubitus exist POA?

Where was patient admitted
from?

Is there a skin exam in the ER
or by the admitting physician?

Check the H&P.

Skin breakdown, redness,
when was this initially noted
and by whom?


Before skin breakdown into
an ulcer – redness
Is the diagnosis of “ulcer”, the
type, the stage, and POA
clearly documented?
Physician query is required.
Superficial well-defined decubitus
ulcer
Wound progression


“It is possible for a wound to
"go from a stage I wound to a
stage III or IV" without the
intermittent stage[s] being
observed.
All wound stages were present
just not obvious, hence the
need to treat all wounds as
serious with the potential of
rapidly worsening.”
www.expertlaw.com/library/
malpractice/decubitus_ulcers.html
Stage 4 decubitus ulcer
Values Commonly Used to Grade the Severity of Protein-Energy Malnutrition
Measurement
Normal
Mild Malnutrition
Moderate
Malnutrition
Severe Malnutrition
Normal weight (%)
90–110
85–90
75–85
< 75
Body mass index
19–24*
18–18.9
16–17.9
< 16
Serum albumin (g/dL)
3.5–5.0
3.1–3.4
2.4–3.0
< 2.4
Serum transferrin
(mg/dL)
220–400
201–219
150–200
< 150
Total lymphocyte
3
count (per mm )
2000–3500
1501–1999
800–1500
< 800
Delayed
hypersensitivity
index†
2
2
1
0
*In the elderly, BMI < 21 may increase mortality risk.
†Delayed hypersensitivity index quantitates the amount of induration elicited by skin testing using a common
antigen, such as those derived from Candida sp or Trichophyton sp. Induration grade 0 = < 0.5 cm, 1 = 0.5–0.9 cm,
2 = ≥ 1.0 cm.
http://www.merck.com/mmpe/sec01/ch002/ch002b.html
Symptoms—Diagnoses?

Different diagnosis potential, different codes, and different MSDRGs, with different reimbursement:
– Seizure–100-101
– Syncope–312

–
Orthostasis

–
–
–
–
–
–
Near syncope
Orthostatic hypotension–312
Vertigo, dizziness – (dysequilibrium)–149
Weakness–947-948
Altered mental status–947–948
Decreased level of consciousness
Alteration of consciousness—081
Dementia—884
Underlying cause due to more
specific diagnosis?
SOB
Distress
AMS
Clarify Underlying
Cause
Chest Pain
Mass
Insufficiency
Hypoxia
Weakness
Encephalopathy choices—
Many types, many codes, many MS-DRGs, and RW difference
Alcoholic 291.2 MS-DRG 894-896 (FY08: 0.3571–1.0419, FY9: 0.3878-1.327)
Chronic cerebral ischemic 437.1 – MS-DRG 069 (FY08: 0.7339, FY09: 0.7157)
Due to dialysis 294.8-MSDRG 884 (FY08: 0.8431, FY09: 0.8992)
Hepatic 572.2 – MS-DRG 441-443 (FY08: 1.3973 – 0.9079, FY09: 1066390.6982)
Hypertensive 437.2 – MS-DRG 077-079 (FY08: 1.4611-0.9839, FY09: 1062330.7398)
Hypoglycemic 251.2 or – Wernicke’s 265.1 MS-DRG 640-641 (FY08: 0.97930.7248, FY09: 1.1138-0.6820)
Metabolic 348.31 or Unspecified 348.30 – MS-DRG 070-072 (FY08: 1.62120.9586, FY09: 1.8246-0.7650)
Post-traumatic 310.2 – MS-DRG 101-102 (FY08: 0.8258-0.8710, FY09: 0.76170.9584)
Toxic and Toxic-metabolic 349.82 – MS-DRG 091-093 (FY08: 1.3242 – 0.7710,
FY09: 1.5747-0.6777)
Stroke MS-DRGs and weights
Acute ischemic
Intracranial
stroke with use of
hemorrhage or
thrombolytic agent infarction
Nonspecific CVA
061: w MCC –
FY08-2.5541
FY09-2.8717
064: w MCC
FY08-1.5470
FY09-1.8450
067: w MCC
FY08-1.2194
FY09-1.3873
062: w CC
FY08-2.0886
FY09-1.9537
065: w CC
FY08-1.1901
FY09-1.1760
068: w/o MCC
FY08-0.9131
FY09-0.8457
63: w/o CC/MCC
FY08-1.8642
FY09-1.5143
066: w/o CC/MCC
FY08-1.0303
FY09-0.8439
TIA – 069
FY08-0.7339
FY09-0.7157
and precerebral
occlusion without
infarction
Sepsis clinical definitions
1991 ACCP/SCCM consensus conference definitions



Sepsis = Infection + SIRS*
Severe Sepsis = Infection + SIRS + Organ Dysfunction
Septic Shock
= Infection + SIRS + Organ Dysfunction + Hypotension
*Note:
SIRS= Systemic Inflammatory Response Syndrome
Diagnosis
Sepsis
Severe sepsis
Definition
Nonspecific laboratory finding of bacteria in the blood with no signs of
illness.
Systemic disease associated with the presence and persistence of
pathogenic microorganisms in the blood. Clinical manifestations may be a
positive blood culture and fever.
Infection-induced syndrome in the presence of two or more manifestations
of SIRS without organ dysfunction. Septicemia that has advanced to
involve two or more manifestations of SIRS.
Two or more manifestations of SIRS with organ dysfunction.
Septic shock
Severe sepsis in which the cardiovascular system begins to fail, blood
pressure drops, and vital organs are deprived of adequate blood supply .
Bacteremia
Septicemia
Chronic kidney disease codes, GFR,
and weights



Stage I Kidney damage
with normal or high GFR
> 90585.1
Stage II Kidney damage
with mild decrease in
GRF 60-89585.2
Stage III Moderate
decrease in GFR 30-59
585.3
Stages I-III non CCs

IV Severe decrease in
GFR 15-29
585.4

V Kidney failure .15 (or
dialysis)
585.5

End Stage Renal Disease
585.6
HTN chronic kidney disease
code each stage
HTN/HEART kidney disease
Stages IV –V CCs, Stage VI
MCC
Simple pneumonia MS-DRGs


MS-DRG 195 Simple Pneumonia without MCC/cc
– RW .8398 - FY08, 0.7316-FY09
– GMLOS = 3.5
– Multiple 5000 x RW .8398 = $4199.00 - $3658
MS-DRG = DRG 194 Simple Pneumonia with cc
– RW = 1.0235 - FY08, 1.0056-FY09
– GMLOS = 4.4
– Multiple 5000 x RW 1.0235 = $5117.50 - $5028

MS-DRG = DRG 193 Simple Pneumonia with MCC
– RW = 1.2505 - FY08, 1.4327-FY09
– GMLOS = 5.4
– Multiple 5000 x RW 1.2505 = $6252.50 – $7163.50

Hospital Base Rate = $5000
Respiratory failure

518.81 Acute Respiratory Failure = MCC

518.84 Acute & Chronic Resp Failure = MCC

518.82 Other pulmonary insufficiency = CC

518.83 Chronic respiratory failure = CC

Both are defined as an inadequate gas
exchange by the respiratory system where the
lungs cannot take in sufficient O2 or expel
sufficient carbon dioxide to meet the needs of
the body.
Average national mortality rates

Simple PNA--(DRG 193-195)
–

Complex PNA--(DRG 177-179)
–

20%
Sepsis (DRG 871-872)
–

2.5%
20%
UTI (DRG 689-690)
–
1.5%
CDCI
A Clinical Documentation
Coding Integrity (CDCI)
program is a concurrent,
retrospective, and proactive
multi-disciplinary approach,
with physician involvement
with the goal to improve the
completeness and specificity of
clinical documentation to allow
appropriate capture of patient
severity.
Coders
Physician
Clinicians
Hospital
Leadership
Audience Questions???