Customer Context
One of the largest providers of revenue cycle services to hospitals and healthcare systems contracted with Access Healthcare for inpatient DRG Coding, Inpatient CDI services, and DRG Validation from 2021. As a first step, while embarking on the transition of IP DRG coding & CDI processes to our global delivery locations, Access Healthcare established a multi-level governance and transition team. This team included the client’s HIM leaders, facility-specific hospital staff/ HIIM team members, Access Healthcare’s team of medical coders, and clinical documentation specialists. This case study focuses on the CDI and Coding process transformation of a healthcare system that includes 43 hospitals.
Challenges
Entrusted with the service delivery and process transformation of Coding and CDI for ten hospitals, Access Healthcare commenced the transition with an evaluation exercise.
“Again, I can’t say enough on how great our relationship is and the overall success we are having while working together. I would certainly advocate for AHS to workup more accounts as their overall quality from CDI’s standpoint is superb to that of other competitors.”
Non-standard processes. Our initial evaluation reveals that the internal HIM team had challenges standardizing coding and CDI processes across facilities. We noticed significant differences in documentation, payer-specific guidelines, payment methodologies, and abstraction criteria.
Duplication/Replication of CDI codes by the coding team. Further, during the transition phase, the HIM and coding leaders revealed that the coding team members copied CDI codes without validation.
Long delays in DNFB cases. The facility faced long delays in addressing the Discharges Not Finally Billed (DNFB) cases. The DRG mismatch review between the CDI and coding teams accounted for the highest number of DNFB cases.
Lack of continuous improvement processes. The lack of tight coordination between the CDI and Coding team members meant that the HIM leaders only focused on prospective queries by the CDI team to identify documentation improvement opportunities. The HIM leaders were also concerned about the inability of the coding team to identify retrospective query opportunities.
After a deeper analysis of the underlying issues, Access Healthcare’s CDI and Coding leadership recognized that they must establish a holistic transformation program and not just deploy CDI and Coding resources. Our CDI leadership team instituted a robust governance architecture to streamline processes.
Solutions
Seasoned team and effective audit coverage. Access Healthcare deployed highly experienced inpatient coders and clinical documentation specialists for the healthcare system, establishing a minimum of 30% audit coverage on the processes.
Addressing physician queries. We reviewed all physician queries, missed opportunities, and DRG mismatches before routing them to the client and the hospital’s HIM team.
Created focused audit groups. We established two focused audit groups to address audit findings from four external audit streams, i.e., Enjoin, CloudMed, EIQ, and Payor Audits. Our auditors reviewed the results of these audits. We prepared educational materials and educated the team to reduce ongoing audit feedback.
Operational rigor to fast-track DRG mismatch reviews. We conducted a daily review of all Epic queues with respective leaders in our team to address all documentation queries and follow up on them. We utilized the 3M 360 notification system to fast-track DRG mismatch reviews to reduce DNFB hold time.
Focus on knowledge improvement. Coding and CDI are knowledge-oriented streams. We established robust training and evaluation processes to achieve consistently high results. We conducted weekly tests to assess the knowledge levels of our coders and CDI specialists. We reviewed external and internal audit findings weekly to identify knowledge gaps and train our team members in specific areas.
Governance. We utilized the multi-tier governance architecture with client and facility CDI and Coding leaders to discuss opportunities for more vital collaboration, gauge progress, and identify improvement opportunities.
Results
Maintained DNFB for CDI holds to less than five business days to send to billing to improve collections and accelerate cash flow.
Reduced missed diagnosis codes from over $50K to less than $16K monthly – an over $34K improvement.
Reduced Coding quality issues by revalidating the codes assigned by the CDI team.
Improved and maintained the HAC/PSI reporting rates of the hospital.
Productive retrospective physician queries from coding resulted in greater specificity in documentation and MS-DRG.
Maintained optimal Case Mix Index (CMI) through effective collaboration between Access Healthcare’s CDI and coding teams.
We reproduce below an email from the healthcare system’s regional CDI leader.
“The Access Healthcare team finds potential query opportunities and does a great job supporting their finds when notifying CDI requesting a retro query. The CDI’s coding is not copied and used by coding for the final bill; instead, AHS coders accurately code each chart and work with CDI when there is a mismatch. The DNFB for CDI holds have been significantly reduced at both sites since working with AHS exclusively. Accounts are being dropped for billing by the 5-business day mark.
Last, we have seen a huge reduction in CDI finds where coding may have missed an impacting diagnosis as a PDX/CC/MCC/procedure, etc. Before AHS working up cases, we averaged approximately $50K+ in monthly opportunities. In the last two months, there have only been roughly $16K missed opportunities each month.
Again, I can’t say enough about our relationship and overall success while working together. I agree with Sree that there is always room for improvement, but AHS has done a fantastic job. I would advocate for AHS to work up more accounts as their overall quality from CDI’s standpoint is superb compared to that of other competitors.”