Business of Medicine

1. Business of Medicine Teaches the relationship between • Treatment • Documentation • Reimbursement – Physician and Facility

2. Documentation – Why Does It Matter? • Allows for accurate coding • Increases quality and integrity of the medical record • Improves reimbursement • Data Warehouse and Physician Profiles

3. The Physician’s Role • Requires a thorough accounting of: • Principal Diagnosis • Procedures • Complications • Comorbid Conditions (CC) • Signs and Symptoms when diagnoses are not established • Discharge Status

4. 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.

5. 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

6. 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.

7. 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 DON’TSyncopeEpistaxsisChest pain Ascites Fatigue Hypovolemic shock Azotemia, prerenal Azotemia Hematuria Fever of unknown origin Altered Mental Status (AMS) 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.

8. 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.

9. 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

10. DRG Assignment is Driven by: • Principal diagnosis • Principal procedure • Secondary diagnoses & procedures • Age • Gender

12. 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.

13. 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 patient’s stay. • Any complication or comorbid condition should be documented by a physician within the medial record.

14. 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)

15. “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.

16. Un-reimbursed Care of Fulton and DeKalb County’s Indigents • Since 1993 the amount from Fulton and DeKalb counties to pay for indigent care has been stable at about $100,000,000 • Grady’s budget in 1993 was $335,000,000 • Grady’s budget in 2006 is $704,000,000 • In 2005, Grady had about $235,000,000 in un-reimbursed COSTS from Fulton and DeKalb county’s indigent patients

17. 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 Brown’s ICD-9-CM Coding Handbook2006 (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)).

18. 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 Admininstrator’s Perspective • Physician and Hospital Revenue Cycles