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Anne Robertucci, UPMC Eileen Simmons, UPMC Presbyterian Shadyside Automating Revenue Integrity During the ICD-10 Transition and Beyond UPMC Snapshot $11 billion integrated global health enterprise Western PA’s largest employer 60,000 employees 22 academic, community, and regional hospitals 4,732 licensed beds 187,000+ inpatient admissions 174,000 surgeries performed annually 4.5 million+ outpatient visits 600,000 emergency visits 40+ UPMC Cancer Centers 180 affiliated oncologists UPMC Health Plan: 2 million total members network of 125+ hospitals 11,500+ physicians

Automating Revenue Integrity During the ICD-10 … · Automating Revenue Integrity During the ICD-10 Transition and Beyond UPMC Snapshot $11 billion integrated ... Specificity Physician

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Page 1: Automating Revenue Integrity During the ICD-10 … · Automating Revenue Integrity During the ICD-10 Transition and Beyond UPMC Snapshot $11 billion integrated ... Specificity Physician

• Anne Robertucci, UPMC

• Eileen Simmons, UPMC Presbyterian Shadyside

Automating Revenue Integrity During the ICD-10 Transition and Beyond

UPMC Snapshot

$11 billion integrated global health

enterprise

Western PA’s largest employer

60,000 employees

22 academic, community, and

regional hospitals 4,732 licensed beds

187,000+ inpatient admissions

174,000 surgeries performed annually

4.5 million+ outpatient visits

600,000 emergency visits

40+ UPMC Cancer Centers

180 affiliated oncologists

UPMC Health Plan: 2 million total

members network of 125+ hospitals

11,500+ physicians

Page 2: Automating Revenue Integrity During the ICD-10 … · Automating Revenue Integrity During the ICD-10 Transition and Beyond UPMC Snapshot $11 billion integrated ... Specificity Physician

Clinical Documentation Improvement at

UPMC: The Challenge

• No clinical documentation

improvement (CDI) programs in place

• 100% retrospective focus

• Average 550 inpatient medical

records coded per day

• 5% of the total discharges result

in a query

• Physician query process is

labor intensive

• Queries that are not resolved quickly

impact the DNFB

• 5 FTEs/3 sites

CONCURRENT

100% RETRO

5% = $1M/month

550 records/day

Balancing Organizational Approach with

Physician Needs

Hospital Physicians

Provide education

Clinically relevant

Embedded query workflow

Concurrent querying

FTE neutral solution

Improved outcomes

Compliant practices

Eliminate missed opportunities

Page 3: Automating Revenue Integrity During the ICD-10 … · Automating Revenue Integrity During the ICD-10 Transition and Beyond UPMC Snapshot $11 billion integrated ... Specificity Physician

• Provides a natural language processing (NLP) engine for case-finding by locating cases with

the highest potential for documentation issues within them.

• Eliminates the use of spreadsheets, admission reviews, and other manual methods for

locating cases.

• Decreases the number of chart reviews required to produce a valid query and the time it

takes to review a medical record to validate the presence of a CDI opportunity.

• Develops more compliant queries by providing system references which are based upon the

CDI case finding rules with information already in the medical record.

• With improved precision and recall, allows for a percentage of all queries to be auto-

generated directly to the physician using the auto-query functionality.

• Increases quality scores and metrics for better patient care.

Beyond the EHR - CDI Software and Services

The Tools and the Team

• 9 facilities/15 FTE’s

• Automation reduces staffing requirements for case finding (via

NLP engine)

• Electronic work lists linked directly to electronic health record information

• Work distribution seamless/remote work options for CDI specialists

• Remote physician advisor review work options

• Tool enables CDI Specialist to tag key record components for the provider

to review seamlessly during query completion

• Electronic query capability within physician workflow reduces response

time and increases physician satisfaction

• Integration of coding within CDI workflow

Page 4: Automating Revenue Integrity During the ICD-10 … · Automating Revenue Integrity During the ICD-10 Transition and Beyond UPMC Snapshot $11 billion integrated ... Specificity Physician

Striving Toward a Field of CDI

Dreams – The UPMC Story

Co-developed the first

inpatient computer-

assisted coding (CAC)

solution, launched in 2008.

CMI by 8%

Coder productivity by 20%

External audits by 50%

Coder overtime

CDI Technology — How it Works

Concurrent CDI Case Finding

Continuous processing of EMR data through NLP engine to code and apply case-finding rules to each admission

If a case is marked for CDI, ensure that it conforms to business rules for presentation to a user:

• Financial class

• Revenue code

• Physician service

• Location

How should it be routed?

• Direct to physician

• Peer advisor

• CDI specialist/manager

• Specific user/coder

Business Rules Logic

Query passively built with minimal (if any) additional editing and update required by CDIS

Presentation to physician either interfaced to EMR via Inbox or PQRT Portal

Passive Query Building

Query response returned to NLP

Page 5: Automating Revenue Integrity During the ICD-10 … · Automating Revenue Integrity During the ICD-10 Transition and Beyond UPMC Snapshot $11 billion integrated ... Specificity Physician

Two Types of CDI Opportunities Test

Optum NLP Capability

Example 1: Specificity

Physician documents “CHF improving.”

Example 2: Clinical Clarity

Physician documents “fluid retention and

shortness of breath improving.”

NLP Identifies

• “CHF” in history and physical

• “CHF” in progress note

• Suggests code for unspecified CHF

NLP Identifies

• Pulmonary vascular congestion in CXR

• Ejection fraction of <30% in echo

• BNP of 700

• IV Lasix in MAR

Approach to Query

• Engage physician to provide specificity in

CHF diagnosis

– Acute vs Chronic

– Diastolic vs Systolic

Approach to Query

• Engage physician to clarify clinical facts

• Ascertain if there is a diagnosis that could be added to

reflect the clinical picture and rationale for treatment of

this patient

• Subsequent query for specificity in diagnosis if indicated

Discrete

data

High

difficulty

Easy to

moderate

The Challenge

(or business goal)

System-built

queries vs.

manually-built

Page 6: Automating Revenue Integrity During the ICD-10 … · Automating Revenue Integrity During the ICD-10 Transition and Beyond UPMC Snapshot $11 billion integrated ... Specificity Physician

Transitioning to the New

Technology Solution

• Inpatient documentation review (i.e. queries); NLP automation

opportunities identified

• CDI classroom education for re-tooled DRG Specialists

• Clinical indication training specific for coders to understand markers

• Interface testing – key to success is data!!! (28+ interfaces)

• Application use-case testing with super users

• Technical training of providers and re-tooled DRG Specialists

• Implementation rollout by facility

• Consistent testing and adherence to project plan repeated for each rollout

• Monitoring of key metrics….

The Challenge

(or business goal)

UPMC Optum

CDI Outcomes

Page 7: Automating Revenue Integrity During the ICD-10 … · Automating Revenue Integrity During the ICD-10 Transition and Beyond UPMC Snapshot $11 billion integrated ... Specificity Physician

Optum CDI Queries Yielding ROI

Most frequent service

lines queried:

• Cardiology

• Medicine

• Oncology

Physician Query Response Rates

Comparing Paper Query to Optum CDI

Page 8: Automating Revenue Integrity During the ICD-10 … · Automating Revenue Integrity During the ICD-10 Transition and Beyond UPMC Snapshot $11 billion integrated ... Specificity Physician

Physician Query Average Turnaround

Time Comparing Paper Query Process

vs. Optum CDI

Coding TAT to Final Bill

Cases with a Query 2012 vs. 2013 (average, days)

Page 9: Automating Revenue Integrity During the ICD-10 … · Automating Revenue Integrity During the ICD-10 Transition and Beyond UPMC Snapshot $11 billion integrated ... Specificity Physician

UPMC CC/MCC Capture Improvement

• Electronic CDI Improvements

– 3% Improvement CC/MCC at Presbyterian/Shadyside Hospitals

– 4% Improvement CC/MCC at St. Margaret Hospital

25% 28% 17% 21%

31% 31%

32% 32%

Manual CDI Optum CDI Manual CDI Optum CDI MCC CC

Presbyterian/Shadyside St. Margaret

Physician Query-Related DRG Shift

105 96

41

9 3 7 2

26

133

42 32

9 14 7

0

20

40

60

80

100

120

140

A: < 1 B: 1 - 2 C : 2 - 3 D: 3 - 4 E: 4 - 5 F: 5 - 6 G: > 6

Original DRG Revised DRG

DRG shift related to queries that changed the MSDRG

Page 10: Automating Revenue Integrity During the ICD-10 … · Automating Revenue Integrity During the ICD-10 Transition and Beyond UPMC Snapshot $11 billion integrated ... Specificity Physician

Pilot: Value of Automated CDI to UPMC

Impact of

more accurate

documentation

$1,321,880 ÷ 5359 cases = $247/case

UPMC performed an audit of the

Clinical Documentation

Improvement (CDI) physician

queries for all discharged patient

records from UPMC

Presbyterian, Shadyside and St.

Margaret Hospitals from

November 10, 2013, through

December 8, 2013.

A total of 5,359 discharges and

corresponding queries were

evaluated which provided a total

value of $1,321,880 in expected

additional revenue. An

extrapolated value per discharge

results in $247 per case. $2.1M $2.6M

$3.4M $3.6M

$5.8M

$7.7M

$3.9M $3.7M

$32.8M*

Projected annual income

UPMC: All hospitals $32.8M

Presbyterian McKeesport/ Horizon/

Northwest

Mercy Hamot/ Bedford

St. Margaret Passavant/ East

Magee

Shadyside All UPMC

Roadmap to ICD-10

• Tool enables use of technology for creation of query templates required with ICD-10 implementation

• CDI Specialists and Coders ‘training’ sandbox in one integrated solution

• UPMC utilizing ICD-10 trained coders to serve as feedback loop for physician documentation issues identified during dual coding period

• Dual coding enables NLP engine to further enhance ICD-10 precision and recall rates

Page 11: Automating Revenue Integrity During the ICD-10 … · Automating Revenue Integrity During the ICD-10 Transition and Beyond UPMC Snapshot $11 billion integrated ... Specificity Physician

Automated CDI and Quality

• Virtual work lists enable UPMC CDI Specialists to query concurrently for SOI/ROM measures as well as for MS-DRG opportunities

• SOI/ROM scores integrated within their workflow; Coder and CDI Specialist roles both have direct access to weighting and scores

• SOI/ROM directly impact hospital HealthGrade reports as well as physician OPPE benchmarks

Conclusions

• Opportunities are bountiful

• Technology opens door to efficiency

• Metrics are key to monitoring progress

• Journey just beginning for us…

Page 12: Automating Revenue Integrity During the ICD-10 … · Automating Revenue Integrity During the ICD-10 Transition and Beyond UPMC Snapshot $11 billion integrated ... Specificity Physician

Thank you!