Business of Medicine

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Business of Medicine

• Teaches the relationship between
• Treatment
• Documentation
• Reimbursement Physician and Facility

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Documentation Why Does It Matter?

• Allows for accurate coding
• Increases quality and integrity of the medical
  record
• Improves reimbursement
• Data Warehouse and Physician Profiles

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The Physicians Role

• Requires a thorough accounting of
• Principal Diagnosis
• Procedures
• Complications
• Comorbid Conditions (CC)
• Signs and Symptoms when diagnoses are not
  established
• Discharge Status

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Definition of Principal Diagnosis

• The condition established after study to be
  chiefly responsible for occasioning the admission
  to the hospital.
• When the patient presents, upon admission, with
  two or more interrelated conditions, each
  potentially meeting the definition for principal
  diagnosis and all are treated, either diagnosis
  may be sequenced as the principal diagnosis.

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The Documented Diagnosis Has to be Specific

• ICD-9-CM codes are only applied to diagnoses that
  are shown to have clinical significance as
  documented by the physician. It is imperative
  that physician documentation in the progress
  notes address laboratory data and other
  diagnostic tests.
• Diagnosis coding is a more difficult area than
  procedure coding because of the complexity of
  arriving at precise diagnoses and the sequencing
  of diagnoses

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UNCERTAIN DIAGNOSES

• If the diagnosis documented at the time of
  discharge is qualified as
• Probable
• Possible
• Likely
• Questionable
• Suspected
• or still to be ruled out
• The condition will be coded as if it existed or
  was established. The basis for these guidelines
  are the diagnostic work-up, arrangement for
  further work-up or observation, and the initial
  therapeutic approach that correspond most closely
  with the established diagnosis.

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CODING SIGNS/SYMPTOMSCodes for signs, symptoms
and ill defined conditions are not to be used as
principal diagnosis when a related definitive
diagnosis has been established.

• DOSyncope due to 3rd degree AVB
• Epistaxsis due to HypertensionCP probably
  due to Unstable AnginaCP due to GERDAscites
  possible due to Acute Cirrhosis of the
  LiverFatigue due to HypothyroidismHypovolemic
  Shock due to Severe DehydrationAzotemia due to
  Acute/chronic renal failure
• Hematuria suspect UTI
• FUO, Suspect Sepsis or UTI
• Altered Mental Status due to Hyponatremia

• DONTSyncopeEpistaxsisChest pain
• Ascites
• Fatigue
• Hypovolemic shock
• Azotemia, prerenal Azotemia
• Hematuria
• Fever of unknown origin
• Altered Mental Status (AMS)

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RBRVS

• A payment methodology for Medicare (and Medicaid
  in Georgia) which has three components
• a relative value for each procedure,
• a geographic adjustment factor,
• and a dollar conversion factor.

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Components of the RVU

• RVU has 3 components
• Work Amount of time and effort
• Practice Expense equipment / supplies
• Malpractice Expense increased risk by specialty
• RVUs are associated with CPT codes they are NOT
  associated with ICD-9 diagnosis codes

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• DRG Assignment is Driven by
• Principal diagnosis
• Principal procedure
• Secondary diagnoses procedures
• Age
• Gender

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Case-Mix Index (CMI)

• The sum of all DRG relative weights, divided by
  the number of Medicare cases. A low CMI may
  denote DRG assignments that do not adequately
  reflect the resources used to treat Medicare
  patients.

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COMORBID CONDITIONS/COMPLICATIONS

• Complication A condition that arises during the
  hospital stay and extends the LOS by at least one
  day.
• Comorbidity A pre-existing condition that will,
  because of it presence with a specific principal
  diagnosis, will extend the LOS by one day.
• These conditions need to be under treatment
  actively or prophylactically during the patients
  stay.
• Any complication or comorbid condition should be
  documented by a physician within the medial
  record.

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Healthcare Team Opportunities

• Sign the papers!!!!
• If you think you might, maybe, could need Home IV
  ABX tell us right now!!!
• Do write a disposition plan everyday
• It is never too soon to tell the RN or SW Care
  Manager your plans for discharge (ie equipment,
  O2, Home Health etc)

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Dish Funds DSH

• Disproportionate Share Hospital Payments
• Payments through the Georgia ICTF program to
  hospitals.
• Hospitals must meet state and federal standards
• Payments based on a DSH Cap for the hospitals
  un-reimbursed Medicaid costs plus the costs of
  caring for uninsured patients
• No state funds are used, federal money is drawn
  down by individual hospitals having to send
  money to CMS which is matched and sent to the
  state.

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Un-reimbursed Care of Fulton and DeKalb Countys
Indigents

• Since 1993 the amount from Fulton and DeKalb
  counties to pay for indigent care has been stable
  at about 100,000,000
• Gradys budget in 1993 was 335,000,000
• Gradys budget in 2006 is 704,000,000
• In 2005, Grady had about 235,000,000 in
  un-reimbursed COSTS from Fulton and DeKalb
  countys indigent patients

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REFERENCES

• DRG Expert (A comprehensive guidebook to the DRG
  classification system)
• American Hospital Association (AHA) Coding Clinic
  (Official Nationally Recognized Authoritative
  Source for Coding)
• Faye Browns ICD-9-CM Coding Handbook 2006
  (Produced in collaboration with the Central
  Office on ICD-9-CM of the AHA)
• ICD-9-CM Official Guidelines for Coding and
  Reporting (Maintained by American Hospital
  Association (AHA), Centers for Medicare and
  Medicaid Services (CMS), National Center for
  Health Statistics (NCHS), and American Health
  Information Management Association (AHIMA)).

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BOM Sessions FOB 1st Floor3rd Monday Noon each
month

• Upcoming Topics
• Earning your Salary as a Physician
• Time-Based Billing critical care, care plan
  oversight
• Accurately Classifying Consult vs Referral
• Use of Modifiers
• Compliance with an Admininstrators Perspective
• Physician and Hospital Revenue Cycles