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|Entry Title||Physician Coding Audit and Feedback System|
|Submitted by:||Christensen/Roberts Solutions|
|Contact Name:||Lou Roberts|
|Address:||8 Lunar Drive
Woodbridge, CT 06525
The Physician Coding Audit and Feedback System was developed for a renowned cancer diagnosis, treatment and research institution. As part of their clinical duties, physicians must choose billing codes for the Evaluation & Management services provided in their outpatient clinics (the typical patient visit to a doctor). These codes are required by Medicare and other insurers for reimbursement of services. There are three categories of office visits (New Patient, MD-Requested Consultation, and Follow-up), and each category has five different levels based on complexity and other factors for a total of 15 code choices in this setting. It is essential that the physicians follow strict Medicare regulations for choosing the correct code and that their documentation ("note") supports the code chosen. Inaccurate code selection and submission can expose the institution and physician to government investigation, negative publicity, financial penalties, and distraction from patient care.
Over the past 10-15 years, Medicare and the federal government have increased their efforts to investigate healthcare fraud and abuse. Since research has shown inappropriate reimbursement represents a huge dollar amount to the taxpayer, the government and public now demand full accountability of every Medicare dollar spent. Investigations are not limited to flagrant Medicare fraud cases, but also include errors due to lack of knowledge. In addition, the law makes a physician personally liable for improper coding, regardless of who selects the code.
In 2004, Christensen/Roberts Solutions was selected by the cancer center’s Compliance Officer to study their coding selection process in the outpatient clinic with the goal of improving accuracy. The following constraints that inhibited desired performance were presented to CRS:
The original request was to improve code selection accuracy through training. CRS asked for, and was granted, the opportunity to conduct its own independent analysis. CRS retained the services of a physician consultant who acted as the Subject Matter Expert and physician-advocate during the analysis and solution design.
Within six months, CRS presented its results. The analysis determined that:
Upon acceptance of the analysis results, CRS presented the following recommendations:
Provide a detailed description of the overall design and/or specific components. Explain how the solution supports business (organization) and user performance. For example, does it reduce the amount of business knowledge performers require before they can perform the function and, if so, how does it do this? Include supporting graphics, screen shots, animation, or the like here so that we can see the supporting material. Please provide access to the solution via the web or on CD/DVD. If access is restricted, please provide six (6) user IDs and passwords. You may assume that the judges will be using IE6.x or above to view your entry. Be sure to note any plug-ins required and the details for obtaining them if not automatically provided. Your Solution information - including the samples provided - should focus on PCD attributes, including (but not necessarily restricted to):
The result of the recommendation was the design and creation of the Physician Coding Audit and Feedback System. This application was designed to:
The application would improve the performance of five separate audiences.
|Classification and state of deployment:
|How would you classify your
PCD Solution? Check one:
Traditional EPSS - external or extrinsic "EPSS" solutions with designs rooted primarily in learning or reference
Performance-centered workflow solution - any PCD solution with a focus on directly supporting business processes (aka workflow)
PCD makeover - solutions that replace existing user interfaces with ones that exhibit attribute and behaviors of performance-centered systems
Embedded/ intrinsic PCD solution - performer-centered solutions that are strictly embedded in the task context and focus on task completion - not learning - without breaking the task context or flow
PCD featuring innovative technology - any performance-centered solution that features technology other than just a user interface to enable or enhance performance
Other category (describe):
This entry is (check one): In production (being used today in a live work setting) In a formative stage (prototype, proof-of-concept, introduced a sample of its intended users)
1. Supports performers through best practice processes.
A major component of the design and development process was the creation of a single, consistent, institution-wide E&M outpatient coding and auditing process. E&M coding rules are based on confusing Guidelines published by Medicare that are subject to wide variations in interpretation and can lead to conflicting opinions/feedback. As a result, the project team underwent a rigorous, six-month effort to develop a unified, consistent, and defensible audit and feedback process (workflow) that represented the major underpinning of the Coding Audit and Feedback System. The audit and feedback process incorporated input from external and internal subject matter experts, industry best practices, and physician representatives to ensure language and style were appropriate for the physician and auditor audiences.
2. Establishes, or aids in establishing, goals.
Helps performers establish what they can do, want to do, or where to go, based on stored data/information.
The goal of the application is to compare
the code selected by the Physician with the code based on Medicare
this, the code is broken down into its required components: Chief
Complaint (CC); History of Present Illness (HPI); Review of Systems
(ROS); Past, Family and Social Histories (PFSH), History (Hx-Total),
Physical Exam (PE); and Medical Decision Making (MDM-Total). By
comparing the components of the code the Physician chose versus
code, the application can identify the reasons, if any, the code
was incorrect. The comparisons are made possible by converting
the components into numbers. This method allows for easy computerized
comparisons and a more objective approach to judging the documentation.
The goal of the process, comparing the components of the code selected
versus the code selected by Medicare Guidelines, is always visually
apparent in the Single Chart Audit Table (SCAT) at the top right
of the Audit Screen; the components “build” as the Auditor progresses
through the interview.
The data collected via the question and answer interface can be used by the Coding Manager in quality control to identify performance issues. The data would allow the Coding Manager to determine exactly where the auditor’s reasoning went astray, thus aiding greatly in giving the auditors direct feedback.
Auditor workloads can easily be viewed via the middle section of the Desktop module labeled “Charts To Be Audited” which is searchable by auditor’s name. This allows for better workload balancing between auditors.
For Physicians and Hospital Administrators:
The goal of this program is the reduction of coding errors. The application has the ability to report current and prior coding error rates, broken down by Root Cause, Physician and Service. The reports generate the audit results in a quantifiable manner, allowing comparison among individual physicians and services (physician groups). Current vs. Prior results are clearly indicated.)
3. Minimizes terminology translation or interpretation.
All coding terms and language are normalized to the cancer center's standard language to reduce confusion between Medicare terminology and the cancer center-specific terminology.
Numerical translations are automated by the program.
4. Provides access to supporting and learning resources.
The application included rollover definitions and point of performance definitions /explanations bulleted to known areas of previous confusion.
Where more in depth process support is required, the application provides embedded tools and references at the point of need:
5. Focuses on task(s), processes, and the natural flow of work.
The recommended task sequence (workflow) is represented in left Navigation Bar.
The sequence of questions (workflow) quickly identifies documentation omissions which would make the chart Non-Billable, decreasing unnecessary auditing time.
Intrastep workflow is built into the application through input logic; users are guided through the workflow using a simple interview-based question/answer model. Questions are progressively disclosed based on previous answers. Color coding of both left Navigation Bar Steps and Q/A allows for easy detection of what still needs to be completed by the auditor.
In addition, complete backwards-oriented logic is built into application, allowing users to retrace their steps to any point in the interview and resetting the logic state at every point.
6. Reduces or eliminates the need for training/learning.
For the Auditor: The built in interpretations, rollover definitions and code-generating logic decreases the need for auditor training.
For the Physician: The original strategy to achieve coding accuracy was to train each of the 400 physicians who provide this service to patients at the cancer center on the billing and coding rules based on the Medicare Guidelines. However, the performance analysis revealed that those physicians typically repeated the same errors, that the errors fell into one of 13 Root Causes, and that most errors could be eliminated by a short knowledge intervention of approximately 15 minutes. Therefore, with the ability to identify a physician’s individual coding errors and automatically provide specific/directed feedback, the cancer center could eliminate costly and ineffective generic training and reduce the disruption to patient care and research time.
Sample section from Physician Feedback Report.
7. Supports performance FIRST, and learning only as a secondary consequence of doing.
For the Auditor: The structured, guided audit process allows the auditor to complete audits without the need to continually check Medicare rules and regulations. Auditors can concentrate on the major task, since the application performs the analysis and calculations to determine the appropriate codes.
The entire training period for Auditors to learn to use the application was a half-day knowledge transfer during which the Auditors were able to complete an audit by the end of the session. The time to complete an audit was significantly decreased, and the audit results generated much more usable information.
Insert a description of the processes and/or system(s) that were previously used to perform the function that your solution now supports. If a system was used to perform this function, please consider including a screen shot of it.
Prior to our involvement, a general overview of outpatient E&M coding was delivered in a classroom setting during orientation of all new Physicians. A full review of the Coding Regulations was presented using Microsoft® PowerPoint and handouts.
As coding issues came to the attention of the Physician Billing Department or Compliance Office, they were reviewed on a case-by-case basis, addressed individually and usually culminated in a PowerPoint presentation given to all the physicians in that service. All physicians belonging to the affected service were required to attend.
Insert a profile of typical users; their skills, education level, job experience and business knowledge. Did this profile change as a result of implementing the PCD Solution? If so, please explain how.
Coding Auditors - Auditors have an industry coding certification
which covers all areas of health care coding (outpatient E&M
coding makes up a small portion of their expertise). Although a
coding background is still required, many of the variables in performance
outcomes have been reduced by the application built-in support,
accountability, improved quality review and (remove:quantification
of results) and the consistent intepretations of Medicare Guidelines.
Coding Managers - Coding Managers are typically promoted from the Auditor ranks and are expert coders. The manager position required them to coach the auditors. Prior to the implementation of the Audit and Feedback System, the Coding Manager spent a large amount of time reviewing individual audits and preparing feedback reports. The manager had very little time left to spend on quality control of the audit results and had no fixed process for providing consistent feedback to the Auditors. Because the application provides an organized, trackable, audit review process, the Quality Control functionality allows the Coding Manager to increase the efficiency and effectiveness of the auditor coaching and feedback.
Compliance Officer - The Compliance Officer is a high-level administrative position, has a very high level of familiarity with the Cancer Center environment and culture and is able to provide personalized feedback to the physician population in an appropriate manner. Prior to the application, the Compliance Officer spent a large amount of time preparing the post-audit presentations for the physicians, and the presentations were often delivered by the Compliance Officer in order to strike the correct "tone." With the application the Compliance Officer has been freed up to look at the larger institutional implications of the findings, to present the data to the appropriate higher level committees, and to make decisions about the data.
Physicians (although not a "user" of the system, they receive the output - Physician Reports) - Physicians want as much feedback as to the accuracy of their code selection as they can get; they want to do the right thing and want re-assurance that they are doing the coding correctly. The application has allowed for a data-driven, organized, consistent and personalized physician feedback and auditing program.
Insert a summary of any performance improvement data you may have collected. For example, this might include information about reductions in errors, training time, or the time it takes to perform specific tasks.
If this is a prototype or proof-of-concept, what are the anticipated performance improvement results? What formative data have been collected to-date?
The Coding Audit and Feedback System entered into full production on March 1, 2006.
During the initial rollout of the new system, a "high-touch" approach was followed. Auditors and Coding Managers attend each feedback session and initiate the session with a presentation that quickly reviews the importance of coding accurately and an introduction to the new audit system, and then reviews the Service Level Reports (with the results of the recent audit). Discussion ensues regarding reasons for the coding errors (if present). It is expected that after the original round of feedback sessions, the feedback reports generated by the system can be sent directly to the physicians, service chiefs, and hospital administrators, further reducing cost.
The initial rollout to the physicians and administrators has been well received. In the first five months after release, over 200 of the 400 cancer center physicians have been audited and results have been returned to the service chiefs and executive management. Personalized feedback generated by the application has been provided to approximately 75 physicians. By the quality and quantity of targeted questions asked during the feedback sessions, the physicians appear to understand the audit results and feedback, appear to be positively engaged, and agree that the personalized feedback can be put to use immediately. They have also indicated their appreciation for direct feedback as opposed to training, and have shown appreciation that the “solution” to the coding accuracy issue acknowledged (respected) the physician’s extreme time constraints.
It should be noted that a significant part of the initial success of the rollout of the application was due to careful attention to the "people side of change" and the incorporation of a formal change management process. It is our experience that even the best designed technology solutions often fail due to an underestimation and lack of preparation for all the resistance to come (a change in the way people work, especially when it impacts a large and varied audience such as the case in this project). Resistance, manifested in its different forms, was encountered throughout the design, development and implementation phases, but the Change Management preparation aided greatly in dealing with it. We would like to acknowledge the help of the folks at Prosci Corporation whose change management process was used.
Among the unanticipated positive outcomes of the project is the decision to hire an outsourcing company to fulfill the Coding auditors' function, reducing operating costs and allowing the cancer center Coding Auditors to serve the more important and higher-skilled function of Quality Assurance and providing feedback to physicians. This decision was made possible by the realization that the application, through its structured workflow and integrated Guideline interpretations, made it possible to use non-cancer center resources.
Coding Auditors have reported a significant increase in job satisfaction by being able to spend more time providing feedback to physicians. Auditors have indicated their satisfaction with the efficiency and accuracy of the application.
The Compliance Officer has already used the initial data generated by the application in executive-management presentations for policy-setting and resource allocation purposes.
The Auditing Manager has reported more effective and efficient coaching sessions with the Auditors using the printable Chart Summary and the Q/A functions.
Although most statistics are not available at the moment, the following data are presently being collected to measure business results:
Describe anything else that contributes to your submission being an exceptional and/or innovative PCD Solution entry.
Feedback from the cancer center Compliance Officer: “[Physician Coding Audit and Feedback System] is a powerful and easy-to-use application that elegantly reduces an unbearably complex process to something manageable and comprehensible.”