Transcript Document

Emergency Services
Session Goals
1. Why Focus on Your Emergency Department.
Review Emergency Department Trends.
2. Proper Emergency Department E&M Levels.
3. Establishing meaningful leveling methodology to capture
resources.
4. Appropriate clinical supporting documentation for levels and
critical care.
5. E.D. Patient Discharge Process
Point of Service Collections
Service Recovery
Why Focus On Your Emergency Department?
Front Door To The Health Care System
Why Focus On Your Emergency Department?
• Major Feeder to the hospital.
– Greatest Source of Admissions.
– 40-80% of Inpatient and Observation patients come from the ED
• Easy way to compete with less efficient hospitals
• Improves Market Share: Extraordinary Patient Focused Care
Why Focus On Your Emergency Department?
• Reasons for ED Overcrowding
– Baby Boomers coming of Medicare age
– 7% decrease in number of ED’s with a 32% increase
in ED Visits the last 10 years.
– PCP shortage: National Problem, Generational
Differences
– Health care reform: Uninsured
Insured,
Increase in ED Visits for primary care.
– Safety Issues
Crowded emergency departments
linked to more deaths, costs
Patients admitted during high ED crowding have 5% greater risk of dying
December 6, 2012 | By Alicia Caramenico
High emergency department crowding is associated with increased
inpatient mortality, as well as moderate rises in length of stay and costs,
concludes a new study in the Annals of Emergency Medicine.
Patients admitted to the hospital during high ED crowding times had 5
percent greater risk of inpatient death than similar patients admitted to
the same hospital when the ED was less crowded.
The researchers looked at almost 1 million ED visits resulting in admission to 187 hospitals and used
daily ambulance diversion to measure ED crowding, according to a research announcement today.
They found that on days with a median of seven ambulance diversion hours, admitted patients had a 0.8
percent longer hospital length of stay and 1 percent higher costs.
Crowded emergency departments
linked to more deaths, costs
Moreover, high ED crowding was associated with 300 excess inpatient deaths, 6,200 hospital days and
$17 million in costs, the study noted.
Such findings are even more worrisome, given that half of health leaders say their ERs are overcrowded
as is. Overcrowding is growing twice as fast as ER visits.
Hospitals looking to make their EDs less crowded should target Medicare patients, as almost 60 percent
of their ER visits were "potentially preventable."
However, contrary to popular belief, nonurgent, Medicaid patients aren't clogging up the ED. Most
Medicaid ED patients go because they have to, seeking emergent care for serious medical problems.
Instead, most crowding stems from ED boarding, in which emergency patients admitted to the hospital
are waiting for an inpatient bed, FierceHealthcare previously reported.
Researchers say the new study reinforces calls to end ED boarding. "Prolonged boarding times may
delay definitive testing and increase short-term mortality, length of stay, and associated costs," the study
states
Overcrowding and Pain Management
•
Annual ED visits have increased in the past 10 years from 90.3 to 119.2 million (32%
increase). With the new healthcare bill it is expected that the average ED will have
increased volume of 6,500 patient visits.
•
Number of ED’s have decreased 4019 to 3833, a 7% loss.
•
Less ED’s and more ED visits have resulted in ED overcrowding.
•
Pain has been deemed the “fifth vital sign” that should be routinely monitored. It is one
of the leading complaints for patients in the emergency department. Knox, T. MD, MPH,
Medscape Emergency Medicine. 2009 Mount Sinai School of Medicine reported a study
of ED overcrowding and pain management.
•
The authors showed at peak census, that on average, patients waited 55 minutes longer
for pain assessments and 43 minutes longer to receive analgesics. Hwang, U. Acad.
Emergency Medicine 2008; 15: 1248 –1255
•
CMS will monitor throughput beginning in 2011 and pay hospitals for performance.
National Quality Forum-approved
benchmarks for emergency care
Centers for Medicare & Medicaid Services pilot program started
1st Qtr 2011
74 hospitals were the first to volunteer their data and show wide
variation across the country.
Reporting for all hospitals, based on a 2% pay-for-performance
incentive, began Jan. 1, 2012
Health Leaders Media, May 7, 2012
National Quality Forum-approved
benchmarks for emergency care
• The number of minutes between the time the patient arrives
at the ED to the time they depart the premises of the ED to be
admitted to the hospital. (ED-1)
• The time between the moment a decision is made by the ED
physician to admit the patient to a hospital bed to the time the
patient departs the ED and is actually placed in an inpatient
bed, a period sometimes referred to as "boarding.“ (ED-2)
• Starting January 1, 2012 a third wait time measure (ED-3) for
patients treated and released.
Health Leaders Media, July 28, 2011
ED-1 Measurement:
Arrival to admission time on the floor
• Niagara Falls Memorial Hospital, Niagara Falls, NY
387 minutes
• Memorial Hermann Baptist Hospital, Orange, TX
358 minutes
• Perry Memorial Hospital in Perry, OK
52 minutes
• Paynesville Area Hospital, Paynesville, MN
90 minutes
Health Leaders Media, May 7, 2012
ED-2 Measurement:
ED Physician decision time to admit
to admission time on the floor
• Memorial Hermann Baptist Hospital in Beaumont, TX
170 minutes
• Niagara Falls Memorial Hospital, Niagara Falls, NY
170 minutes
• Frio Regional Hospital, Pearsall, TX
0 minutes
• Pocahontas Memorial Hospital, Buckeye, WV
0 minutes
Health Leaders Media, May 7, 2012
Medical Screening Exam
GOALS:
Patient sign-in starts clock on the patient flow process.
Greet patients as they enter the ED.
Implement initial time goals:
• arrival to start of MSE – 5 min.
• arrival to disposition – 60 min average
• arrival to admission / transfer – 90 min. average
Customer Satisfaction
Average Satisfaction When 5 =
Excellent
Average Patient Satisfaction by Time to Provider Interval
4.4
4.2
4
3.8
3.6
3.4
3.2
0 to 30
31 to 60
60 to 90
Time to Provider Interval
90 +
The More Time Spent
in the Emergency Department
The Less Satisfied the Patient
The amount of time spent in the ED is a critical factor in the overall satisfaction of ED
patients.
The following graph shows that satisfaction declines dramatically after two hours and
continues to fall with each additional hour.
Patient Satisfaction by Time Spent in ED
Overall Patient Satisfaction
95%
90%
85%
80%
75%
70%
65%
0 to 1
1 to 2
2 to 3
3 to 4
Hours
4 to 5
5 to 6
Represents the experiences of 1,524,726 patients treated at 1,656 EDs nationwide
between January 1 and December 31, 2007. Emergency Department Pulse Report
© 2008 by Press Ganey Associates, Inc.
6 >
Lost Revenue compared to % LWBS
Hospital X: % LWBS and Lost Net Revenue
$900,000
$800,000
$700,000
$600,000
$500,000
$400,000
$300,000
$200,000
$100,000
$8%
6%
4%
2%
Industry
Overall Patient Satisfaction Score
Satisfaction with the Emergency
Department by Time of Day Arrived
84.3
82.8
82.1
7AM - 3PM
3PM - 11PM
Time of Day Arrived
11PM - 7AM
Hospital activity by hour of day
4.5
4
3.5
3
ED Patients by Hour of Day
2.5
IN-Patient admissions by hour of day
2
In-Patient Discharges by hour of day
1.5
1
0.5
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Peak In-Patient Discharge time
4.5
4
3.5
3
ED Patients by Hour of Day
2.5
IN-Patient admissions by hour of day
2
In-Patient Discharges by hour of day
1.5
1
0.5
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Peak In-Patient Admission Time
4.5
4
3.5
3
2.5
ED Patients by Hour of Day
IN-Patient admissions by hour of day
2
In-Patient Discharges by hour of day
1.5
1
0.5
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Peak In-Patient Admission
and Discharge Time
4.5
4
3.5
3
ED Patients by Hour of Day
2.5
IN-Patient admissions by hour of day
2
In-Patient Discharges by hour of day
1.5
1
0.5
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
What would happen if we moved discharges
2 hours earlier?
4.5
4
3.5
3
ED Visits by hour of day
2.5
2
In-patient admissions by hour of day
1.5
In -patient discharges by hour of day
1
0.5
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
NEDOCS
• National Emergency Department
Overcrowding Scale
• Full Capacity Protocols
INSTITUTIONAL
CONSTANTS
COMMON ELEMENTS
MODEL SPECIFIC
Number of ED Beds
Number of Hospital Beds
Total Patients in the
ED
Number of Respirators in
the ED
Total Admits in
the ED
Waiting room wait time
for last patient called
(In hours)
NEDOCS SCOREClear Fields
http://hsc.unm.edu/emermed/nedocs_fin.shtml
Longest admit time
(in hours)
NEDOCS
00 to 20
Not busy
•
•
•
•
21 to 60
Busy
61 to 100
Extremely busy
but not
overcrowded
101 to 140
Over-crowded
141 to 180
Severely
over-crowded
181 to 200Dangerously
over-crowded
Develop Full Capacity Protocol Work Group of department heads and staff.
Incorporate NEDOCS into your protocol
Include Clinical and Non-Clinical areas into your protocol
Consider Incident Command as part of your protocol
CHARGES
Effective charge captures process
ED CHARGES
• Hospitals have traditionally viewed ED’s as cost centers
• ED margin management typically means reducing cost,
often through painful staff reductions.
• Hospitals can have multi-million dollar impact on their ED
margins by aggressively managing top-line revenues
through optimized facility evaluation and management
(E/M) charges and point-of-service (POS) cash collection.
Advisory Board
ED CHARGES
Inconsistent ED Coding Rampant
E/M codes for patients with CT Scans
Level 5, 39%
Level 1-3,
25%
Level 4, 37%
n=17 hospitals
Source: Advisory Board
ED CHARGES
• Documentation is key to the E/M charging process
• ED Directors typically do not manage the E&M charge process well.
• REASONS:
– Lack of tools and information
– Poor communications with coders and HIM
– Poor communication or access with the business office to ensure
charges are optimized.
ED management needs easy access to financial information and
collaboration across functional silos to be able to improve financial
performance in the ED.
Advisory Board
E&M Leveling
• There are no national guidelines for hospital out-patient and
emergency department E&M (Evaluation & Management)
coding to date.
• CMS has stated that each hospital must create their own
guidelines.
• These guidelines should reasonably relate to the resources
expended related to the intensity of the patient’s condition.
• The following is the minimal criteria for E&M leveling from
CMS:
E&M Leveling
CMS E&M Criteria
•
•
•
•
•
•
•
•
•
•
•
•
Follow the intent of the CPT code descriptor in that the guidelines should be designed
to reasonably relate the intensity of hospital resources to the different levels of effort
represented by the code.
Be based on hospital facility resources and not on physician resources.
Be clear to facilitate accurate payments and be usable for compliance purposes and
audits
Meet HIPPA requirements
Only require documentation that is clinically necessary for patient care
Do not facilitate up-coding or gaming
Be written or recorded, well documented, and provide the basis for selection of a
specific code.
Be applied consistently across patients in the clinic or ED to which they apply.
Not change with frequency
Be readily available for FI (or, if applicable, Medicare administrator contractor [MAC]
review)
Result in coding decisions that could be verified by other hospital staff, as well as
outside sources.
(Source: Federal Register, Vol. 72, No.227, p66805)
E&M Leveling
Types of E&M Leveling based on:
• Diagnosis
• Time
• Point System
• Procedures
Or
A combination of some or all
E&M Leveling
Key Elements to Maximizing E&M Leveling and Charges:
• Develop, purchase or “Borrow” an effective leveling tool
• Develop a concurrent chart review system before staff go
home.
• Create a communication system between the HIM coder and
the physician or nursing staff.
• Log and monitor the HIM communications with ED Staff
• Continually educate and remind staff regarding effective
documentation.
Note from the coder
Date:___________
A Note from the Coder:
Please provide the following:
Dictation
Diagnosis
ROS
HPI
Signature
Laceration Length
T-Sheet
Medical Decision Making
FSH
Disposition
Time of Exam Needed:
Physician’s Order Sheet
IV Start/Stop time
Pain Assessment
Critical Care Time
Vital Sign Sheet
Physician Order for___________________________________________________
MISC:_____________________________________________________________
Please return chart to ER clerical desk for re-scanning and then to be
returned to ___________(name)
E&M Leveling
50%
45%
40%
35%
30%
Rev & Usage Report
25%
Goals
20%
15%
10%
5%
0%
LEVEL 1
LEVEL 2
LEVEL 3
LEVEL 4
LEVEL 5
LEVEL 6
Charge Master
• CDM could have approximately 450 line items for
procedures
• Avoid low, moderate, complex bundled charges
• Be sure that bundled procedure charges exceed
Medicare Fee schedule
Documentation
Documentation
Why is documentation so important?
 Communicates to other caregivers what was done
 Facilitates patient care
 Supports data collection
 Reflects quality of decision making
 Justifies legal defense
 Supports regulatory compliance
 Supports fair payment / reimbursement
 Sound professional practice !
Physician and Nursing
Documentation
 ED physician and nursing documentation in some cases is weak or
missing. The documentation does not fully support patient care, correct
coding and accurate charging.
 Examples:
Length of laceration is not always documented.
IV start and stop time is often not documented.
Critical care nursing time is not documented.
Physicians’ charts are not always complete.
Documentation does not always comply with payer and
regulatory guidelines.
- In most cases, provided care supported higher facility E&M
levels.
-
Documentation
Documenting Critical Care
Critical care defines the basis for emergency medicine,
yet it is the most under reported service we do!
Documentation
Definition of Critical Care CPT 99291
“Critical care is the direct delivery of medical care for a critically ill or critically
injured patient. A critical illness or injury acutely impairs one or more vital organ
systems such that there is a high probability of imminent or life threatening
deterioration in the patient’s condition.
Critical care involves high complexity decision making to assess, manipulate,
and support vital system function(s) to treat single or multiple vital organ system
failure and/or to prevent further life threatening deterioration of the patient’s
condition.
Examples of vital organ system failure include, but are not limited to:
central nervous system failure, circulatory failure, shock, renal, hepatic,
metabolic, and/or respiratory failure. Although critical care typically requires
interpretation of multiple physiologic parameters and/or application of advanced
technology(s), critical care may be provided in life threatening situations when
these elements are not present. *
CMS TRANSMITTAL 1548 JULY 9, 2008 http://www.cms.hhs.gov/Transmittals/Downloads/R1548CP.pdf
Documentation
Critical Care Services Physician Time
• The CPT critical care codes 99291 and 99292 are used to report the total
duration of time spent by a physician providing critical care services to a
critically ill or critically injured patient, even if the time spent by the physician
on that date is not continuous.
• Non-continuous time for medically necessary critical care services may be
aggregated. Reporting CPT code 99291 is a prerequisite to reporting CPT code
99292. Physicians of the same specialty within the same group practice bill
and are paid as though they were a single physician (§30.6.5).
Documentation
For CY 2011, the AMA CPT Editorial Panel is revising its guidance for the
critical care codes to specifically state that, for hospital reporting purposes,
critical care codes do not include the specified ancillary services.
Reference: Federal Register / Vol. 75, No. 226 / Wednesday, November 24,
2010 / Rules and Regulations Pg. 71988
Documenting Critical Care
We refer readers to the July 2008 OPPS quarterly update, Transmittal 1536, Change
Request 6094, issued on June 19, 2008, for further clarification about the reporting of
CPT codes for hospital outpatient services paid under the OPPS. In that transmittal, we
note that while CPT codes generally are created to describe and report physician
services, they are also used by other providers/suppliers to describe and report services
that they provide. Therefore, the CPT code descriptors do not necessarily reflect the
facility component of a service furnished by the hospital. Some CPT code descriptors
include reference to a physician performing a service. For OPPS purposes, unless
indicated otherwise, the usage of the term "physician" does not restrict the reporting of the
code or application of related policies to physicians only, but applies to all practitioners,
hospitals, providers, or suppliers eligible to bill the relevant CPT codes pursuant to
applicable portions of the Act, the CFR, and the Medicare rules. In cases where there are
separate codes for the technical component, professional component, and/or complete
procedure, hospitals should report the code that represents the technical component for
their facility services. If there is no separate technical component code for the service,
hospitals should report the code that represents the complete procedure. Consistent with
past input we have received from many hospitals, hospital associations, the APC Panel,
and others, we will continue to utilize CPT codes for reporting services under the OPPS
whenever possible to minimize hospitals’ reporting burden. If the AMA were to create
facility-specific CPT codes for reporting visits provided in HOPDs, we would certainly
consider such codes for OPPS use.
CMS-1404-FC-CMS-3887-F-CMS-3835-F1
Pg 741 - 742
Documentation
Critical Care Billing
 From 1996 to 1999, 1.3% of all ER visits across the nation were billed
as Critical Care.
 In 2000, 1.8% of all ER visits were billed as Critical Care.
Real Life Scenarios —
 Current research shows that at least 5% to 7% of all ER visits should
qualify for Critical Care billing. In 2009 the ED billed <1% Critical Care.
 CMS mandated that critical care nursing time be documented
beginning January 1, 2007. January 1, 2009 requires nursing to
document additional 30 minutes of time (99292).
Documentation
Key indicators for documenting Critical Care
Consider the following interventions as typical of
patients that require critical care:
Airway Monitoring
Any continuous monitoring
Central line placement
Chest tube insertion
CODE STEMI protocol
CPR
Intubation
Physical & Chemical Restraints
Titration of drips
Patients that goes to the OR
on an emergent basis
Emergency Department Patient Discharge
Process
• Point of Service Collections
• Collecting Past Open Balances
• Service Recovery
Disposition POSC
GOALS:






Nursing to escort all ED patients to discharge desk.
Establish a goal of $25 to be collected per discharged patient.
This will increase revenue dramatically and decrease collection costs.
Utilize discharge process to perform financial counseling.
Re-check accuracy of registration.
Service reconciliation.
Service Recovery
• If Service recovery is needed (poor-to-fair
care). “Thank you for your concerns, I
apologize. I will follow up with our manager.”
• “Would you like our manager, name, to call
you back?”
Recognition of Staff
• “Mr. / Mrs. _____________ (name of patient), a last
question for you: Are there any individuals whom you
would like me to compliment for the care they provided? I
would be happy to take their names.”
• Peer to Peer Recognition with this question.
Final Statement to Patient
“You may be receiving a survey phone call. We
appreciate you taking the time to answer the
survey questions as your feedback helps us to
improve our care. Thank you for choosing
Regional Hospital to meet your healthcare
needs.”
Dashboard
Financial
• Charges to budget
• Cost to budget
• Materials Management shrinkage
• Pharmacy shrinkage
• Level statistics
– Facility
– Physician
• Amount collected at time of discharge
• Accuracy of registration
Dashboard
Operations
•
•
•
•
•
•
•
•
•
•
Door to triage time
Door to Doc time
Door to discharge time
Door to admit time
Doctors order to admit time
Average Radiology order to film availability time by top 10 procedures
Average Radiology order to report time
Average Laboratory order time to results reported by top 10 procedures
Monthly volume
– Total
– Treat and release
– Treat and admit
– Treat and transfer
Dashboard
Quality
• Physician Peer review
• Patients who return within 72 hours
• Number of charts returned to staff
• Number of charts down coded
• Quality issues from CMS-Core Measures
• Hemolysis rate
• Level of cleanliness in ED
• Incomplete chart rate
– Facility
– Physicians
Dashboard
Patient Satisfaction
• Press Ganey quarterly report
• AMA
• LWBS
• Patient complaints
• Results from patient survey
• Physician complaints
• Nursing complaints
Thank You