Innovation Storyboard             Abu DhabiEVALUATION & MANAGEMENT CODING    DOCUMENTATION BY PHYSICIANS  – A PROCESS AND ...
1. About the Organization                            Abu Dhabi• NMC Specialty Hospital, Abu Dhabi is a multi‐specialty hos...
1. About the Organization (contd.)                                     3
2. The Idea• How was the opportunity for innovation identified? What was   the business problem/opportunity?  The Health A...
2. The Idea (contd.)• How was the opportunity for innovation identified? What was   the business problem/opportunity? (con...
2. The Idea (contd.)What preliminary research was carriedout (list sources)?• 1995 Documentation Guidelines For  Evaluatio...
2. The Idea (contd.)        DAMAN ABU DHABI PLAN E & M CODES AND PRICESS. No      New Patient        Charges      Establis...
2. The Idea (contd.)• How was the project prioritized?   – The project was given very high priority since it affected the ...
2. The Idea (contd.)                Tools/Techniques to generate the  idea •   Brainstorming •   Revenue projections•   Pr...
2. The Idea (contd.)        Advantages / Disadvantages of various alternatives        Various alternatives were studied an...
2. The Idea (contd.)        Advantages / Disadvantages of various alternatives           ALTERNATIVE II ‐ E & M Coding by ...
2. The Idea (contd.)             ALTERNATIVE III ‐ Outsourcing E & M Coding  • High costs, on par with ALTERNATIVE II• Iss...
2. The Idea (contd.)        Advantages / Disadvantages of various alternatives             ALTERNATIVE IV ‐ E & M Coding b...
2. The Idea (contd.)Disadvantages:• Modification of documentation methodology; this is required even    if the coding is d...
3. People Involvement (contd.)• How was the team formed (cross‐functionality) ?    Interdisciplinary team was formed with ...
3. People Involvement (contd.)• How was the stakeholder buy‐in acquired?   – Having trainers from physicians helped us in ...
3. People Involvement (contd.)• How were the resources / budget determined and obtained   for the project?   – Training co...
4. Process (contd.)• Explain the process of developing the concept into a detailed   plan of a practical solution?   – Stu...
4. Process (contd.)• Explain the process of developing the concept into a detailed   plan of a practical solution? (contin...
4. Process (contd.)    Gantt Chart                      20
4. Process (contd.)• How was the feasibility of the solution evaluated? What   tools/techniques were used for analyzing fe...
4. Process (contd.)• Was any Risk Assessment carried out (risks involved in the   proposed solution itself)?   – Inaccurat...
4. Process (contd.)• How was the Idea (solution) pilot tested for implementation?   • The modified specialty specific form...
4. Process (contd.)                          ROLE INNOVATION• Doctors were trained to code the consultation as a part of t...
4. Process (contd.)                        FORM INNOVATION• Incorporation of E&M coding documentation requirements.• Impro...
4. Process  (contd.) Old version of forms                        26
4. ProcessNew version of forms                       27
4. Process  (contd.)MISTAKE PROOFING• Comprehensive checklist methodology which gives the doctor a reminder   to ask relev...
4. Process (contd.)• How was the full scale implementation planned?   – The assessment forms were further modified based o...
4. Process (contd.)• How were the risks at the various stages of implementation  identified and mitigation planned?   – Th...
4. Process (contd.)• How was the implementation monitored and controlled?                                                 ...
4. Process (contd.)• How were the various stakeholders informed and   their support obtained?  –   Training  –   Meetings ...
5. Results  External audit by 3rd party was completed by 01st Sep 2010           Planned                            Actual...
5. Results (contd.)What were the           actual   benefits    realized    from    theimplementation?– First private sect...
5. Results (contd.)What were the actual               benefits    realized    from     theimplementation? (contd.)The bene...
5. Results (contd.)• List other intangible benefits   – Helped in standardization of documentation   – Enabler for better ...
5. Results (contd.)• How was feedback obtained from various stakeholders? How  were they impacted? What was their percepti...
6. Learning• What Went Well and What Went Wrong?  – What Went Wrong – the date of start of using the     E&M coding based ...
6. Learning (contd.)• Single Point Lesson Learnt?  • Innovation of the current medical documentation to    incorporate E&M...
6. Learning (contd.)What would you do differently  the next time you do a similar project?• We would try to implement it i...
7. Way Forward• How were the team members recognized?  – Coding accuracy was included as one of the     criteria for judgi...
7. Way Forward (contd.)• Future development of the idea or using the same   idea in different applications   –   Nursing e...
Q & A        43
Thank You            44
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WQD2011 - INNOVATION - NMC - Evaluation & Management Coding Documentation by Physicians–A Process and Role Innovation

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Innovation case study submitted by NMC during 3rd Continual Improvement & Innovation Symposium organized by Dubai Quality Group's Continual Improvement Subgroup to celebrate World Quality Day 2011.

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WQD2011 - INNOVATION - NMC - Evaluation & Management Coding Documentation by Physicians–A Process and Role Innovation

  1. 1. Innovation Storyboard Abu DhabiEVALUATION & MANAGEMENT CODING  DOCUMENTATION BY PHYSICIANS  – A PROCESS AND ROLE INNOVATION July ‐ September 2010 NMCSH ‐ AUH 1
  2. 2. 1. About the Organization Abu Dhabi• NMC Specialty Hospital, Abu Dhabi is a multi‐specialty hospital providing quality and trusted secondary and tertiary healthcare services to the people of Abu Dhabi.• Established in 1975.• ISO 9001: 2008 certified, ISO since 2000• Joint Commission International (JCI) accredited – May 2010• Average Out patients (OP) visits – 1400• Number of Patient Rooms / beds ‐ 100• Number of ICU Beds ‐ 7• Number of Nursery Beds ‐ 4• Number of Operation Theaters ‐ 7• Number of Doctors ‐ 150• Number of Nurses and Paramedics ‐ 370 2
  3. 3. 1. About the Organization (contd.) 3
  4. 4. 2. The Idea• How was the opportunity for innovation identified? What was  the business problem/opportunity? The Health Authority – Abu Dhabi (HAAD) had made it a requirement that all healthcare facilities adopt E&M (Evaluation & Management) codes and charges for Out Patient physician consultations. The healthcare facilities of Abu Dhabi should be certified by 01st September 2010 through a 3rd party before they are allowed to do so. The charges as per the E&M codes, is considerably higher than current charges. After this date those hospitals who were not certified would only be allowed to charge a flat rate of AED 68, which is the lowest among the proposed E&M rate for all OP visits (irrespective of the insurance plan). This would be highly unviable option. 4
  5. 5. 2. The Idea (contd.)• How was the opportunity for innovation identified? What was  the business problem/opportunity? (contd.) Projected increase of OP visits by 10‐15% in the year 2011 i.e. 1600 OP visits Projected increase of patients covered by insurance is expected to increase from 90% to 92% We have adopted E&M coding for OP visits as a part of the mission of the hospital i.e. aligning with the healthcare vision of Abu Dhabi. 5
  6. 6. 2. The Idea (contd.)What preliminary research was carriedout (list sources)?• 1995 Documentation Guidelines For Evaluation & Management Services• 1997 Documentation Guidelines For Evaluation & Management Services• Evaluation & Management Services guide• Joint Commission International Accreditation Standards for Hospitals, 3rd Edition,• HAAD Hospital Standards, 2008• Daman Abu Dhabi Plan E & M Codes And Prices (Plan with the lowest rates) 6
  7. 7. 2. The Idea (contd.) DAMAN ABU DHABI PLAN E & M CODES AND PRICESS. No New Patient  Charges Established Patient Charges Code   (in AED) Code (in AED) 1 99201 126 99211 68 2 99202 219 99212 130 3 99203 321 99213 211 4 99204 492 99214 318 5 99205 620 99215 431The Daman Abu Dhabi Plan had prices of AED 65, AED 85, AED 122 for Out Patientconsultation with General Practitioner, Specialist and Consultants during thestudy period. This was the lowest among the insurance charges. 7
  8. 8. 2. The Idea (contd.)• How was the project prioritized? – The project was given very high priority since it affected the  revenue cycle and had a short period for implementation. – Also, it was required to comply with HAAD regulations. 8
  9. 9. 2. The Idea (contd.) Tools/Techniques to generate the  idea • Brainstorming • Revenue projections• Project Study Gap Analysis Talent assessment – Two physicians were deputed , they underwent online training and  also attended workshops regarding coding conducted by the  HAAD. Competency Assessment – This was done to assess the understanding of E & M coding   guidelines by the physicians 9
  10. 10. 2. The Idea (contd.) Advantages / Disadvantages of various alternatives Various alternatives were studied and discussed before  implementation of the project. ALTERNATIVE – I  (not undergoing E&M coding certification)• All types of Outpatient visits would get a flat charge of AED 68 (lowest of Daman, Abu Dhabi plan E&M Charges) irrespective of the  insurance company or complexity and management the illness• There would be a 30.79% loss of revenue i.e. AED 16,253,085• There would also be an opportunity loss of 50.41% i.e.  AED  26,608,865 • Therefore the net loss would be 81.20% i.e. AED 42,861,950  10
  11. 11. 2. The Idea (contd.) Advantages / Disadvantages of various alternatives ALTERNATIVE II ‐ E & M Coding by Certified Coders• Additional revenue generated would be AED 26,608,865 (50.41% )• Very high costs i.e. additional annual cost for 40 coders = AED  2,880,000• 5.46% of the projected gross additional revenue will be spent on  employing coders.• Net increase in revenue = AED 23,728,865 (44.95%)• Lack of certified coders in the local market• Sudden demand for coders in Abu Dhabi alone• Documentation has to be done irrespective of whoever is doing the  coding 11
  12. 12. 2. The Idea (contd.) ALTERNATIVE III ‐ Outsourcing E & M Coding  • High costs, on par with ALTERNATIVE II• Issues with confidentiality of patient information.• Delay in processing claims. 12
  13. 13. 2. The Idea (contd.) Advantages / Disadvantages of various alternatives ALTERNATIVE IV ‐ E & M Coding by PhysiciansAdvantages:• Real‐time coding• Increased sense of ownership for documentation because “Not  documented, not done; not done means will not be paid for”• Low cost, mainly training cost• Less number of coders i.e. annual cost of 4 coders = AED 288,000 • Additional revenue generated would be AED 26,608,865 (50.41% )• AED 288,000 (0.55%) of the projected gross additional revenue of will  be spent on employing coders and AED 30,000 (0.06% )would be  spent on training• Net increase in revenue by AED 26,290,865 (49.80%) i.e. 4.85% more  than when coding by coders  13
  14. 14. 2. The Idea (contd.)Disadvantages:• Modification of documentation methodology; this is required even  if the coding is done by the coders. Based on the study it was decided that Alternative IV ‐ E & MCoding by Physicians would be a sustainable model. 14
  15. 15. 3. People Involvement (contd.)• How was the team formed (cross‐functionality) ? Interdisciplinary team was formed with representation from: – Physicians – Medical records including Medical coders – Insurance – Nurses – Quality department – Administration – Human resources Training team consisted of members from Physicians, medical  records & medical coding specialists  15
  16. 16. 3. People Involvement (contd.)• How was the stakeholder buy‐in acquired? – Having trainers from physicians helped us in understanding their  perception and to reach out to the physicians. – The following advantages were discussed: • Reduction of documentation time • More time for clinical examination & patient interaction • Increase in Department revenue 16
  17. 17. 3. People Involvement (contd.)• How were the resources / budget determined and obtained  for the project? – Training cost – 20,000 AED – External Auditing cost – 10,000 AED TOTAL COST = 30,000 AED – Annual cost of 4 coders = 288,000 AED 17
  18. 18. 4. Process (contd.)• Explain the process of developing the concept into a detailed  plan of a practical solution? – Study of JCI & HAAD standards, E&M documentation guidelines – Training on the E & M coding documentation guidelines – Development of Department specific Assessment forms in  collaboration with physicians, medical coders & quality  department – Training on the new assessment forms – Pilot testing of the forms i.e. 2 forms per physician per  department – Auditing of forms and checking the conformance to  documentation guidelines 18
  19. 19. 4. Process (contd.)• Explain the process of developing the concept into a detailed  plan of a practical solution? (continued…) – Modifying the forms based on the feedback – Retraining based on the deficiencies that are found during audit  of the completed forms – Deployment of the modified forms for all patient visits – Auditing of forms and checking the conformance to  documentation guidelines – External audit by 3rd party – Certification for E&M coding 19
  20. 20. 4. Process (contd.) Gantt Chart 20
  21. 21. 4. Process (contd.)• How was the feasibility of the solution evaluated? What  tools/techniques were used for analyzing feasibility? 1. Competency of the doctors to code using Competency tests. 2. Internal inventory of talent to design an acceptable, compliant  easy‐to‐use form‐ using Talent inventory. 3. Revenue projection‐ Net revenue gain of AED 26,290,865  (49.80%) 4. Opportunity loss of AED 42,861,950 (81.20%) 21
  22. 22. 4. Process (contd.)• Was any Risk Assessment carried out (risks involved in the  proposed solution itself)? – Inaccurate coding – risk – Irrecoverable receivables due to insurance rejection. – Comparison of Financial risk of proceeding with certification and  not proceeding with the same. 22
  23. 23. 4. Process (contd.)• How was the Idea (solution) pilot tested for implementation? • The modified specialty specific forms that were developed were  pilot tested i.e. 2 forms per physician per department • These forms were audited by the coders and the quality  department on a daily basis • Feedback about the forms received from the physicians i.e.  spacing, addition, deletion etc. • Feedback provided to the doctors about the completeness and  accuracy of the documentation 23
  24. 24. 4. Process (contd.) ROLE INNOVATION• Doctors were trained to code the consultation as a part of their  documentation. Doctors therefore took on the role of the coder  thus reducing the need for  separate coders for E&M coding. • Thus, a costly layer of coders in the process of finalizing the claim  was removed. A significantly lesser number of coders (thin layer)  are involved in audits and personal feedback to ensure a sustained  level of high accuracy of coding. 24
  25. 25. 4. Process (contd.) FORM INNOVATION• Incorporation of E&M coding documentation requirements.• Improved data capturing by tick marks instead of free hand writing. 25
  26. 26. 4. Process  (contd.) Old version of forms 26
  27. 27. 4. ProcessNew version of forms 27
  28. 28. 4. Process  (contd.)MISTAKE PROOFING• Comprehensive checklist methodology which gives the doctor a reminder  to ask relevant questions. • Incorporates the coding calculation as a part of the flow of the document  capturing, enabling the doctor to score along the way.What were the results for the pilot trials? – Results showed a coding accuracy of 80.6% during pilot trials. 28
  29. 29. 4. Process (contd.)• How was the full scale implementation planned? – The assessment forms were further modified based on the  feedback – Retraining was done focusing on deficiencies found during the  audit of the completed forms – Deployment of the modified forms for all patient visits from 15th July,  2011 – A continuous audit of forms was performed to ensure the  highest  accuracy – Target was to obtain a E &M coding accuracy of 90% and overall  coding accuracy of 95% by 30 August 2010 29
  30. 30. 4. Process (contd.)• How were the risks at the various stages of implementation identified and mitigation planned? – The  inaccuracies identified were under‐coding, over‐coding and  incomplete documentation – One to one feedback was provided to the physicians – Assessment forms were further modified with inputs from the  physicians to make it user‐friendly – Coding audit process was started to ensure that the process of  coding was correctly complied with and led to highest accuracy  of coding (please refer next slide). 30
  31. 31. 4. Process (contd.)• How was the implementation monitored and controlled? 31
  32. 32. 4. Process (contd.)• How were the various stakeholders informed and  their support obtained? – Training – Meetings – Administrative Rounds – One‐to‐one communication – Intranet communications 32
  33. 33. 5. Results External audit by 3rd party was completed by 01st Sep 2010 Planned Actual• E & M coding Accuracy – 90% • E & M coding Accuracy – 91%• Overall coding accuracy – 95% • Overall coding accuracy – 97% 33
  34. 34. 5. Results (contd.)What were the actual benefits realized from theimplementation?– First private sector hospital in Abu Dhabi to complete coding audit successfully.– Improvement of overall medical documentation– Lesser time spent for medical documentation.– Annualized increase in net revenue of AED 26,290,865 (49.8%)– A saving of salary expenses for additional coders of AED 2592000– An avoidance of an opportunity loss of AED 42,861,950 (81.2%) 34
  35. 35. 5. Results (contd.)What were the actual benefits realized from theimplementation? (contd.)The benefits support the strategic objectives and mission of the hospital:1. Increasing net revenue.2. Decreasing expenses.3. Increased patient satisfaction.4. Compliance with regulatory requirement. 35
  36. 36. 5. Results (contd.)• List other intangible benefits – Helped in standardization of documentation – Enabler for better documentation – Address the issue of illegibility of doctor’s notes – Helped in preparation of templates for Electronic medical record – Replication of the same documentation methodology across 3  hospitals under NMC healthcare  – Increased efficiency of physicians – More time for physician‐patient interaction 36
  37. 37. 5. Results (contd.)• How was feedback obtained from various stakeholders? How were they impacted? What was their perception?1. Patient satisfaction survey.2. Feedback from doctors3. Coding audits by coders4. Feedback from insurance department.The overall impact was a positive one. The doctors found the new assessment form quite time saving and easier to use.  37
  38. 38. 6. Learning• What Went Well and What Went Wrong? – What Went Wrong – the date of start of using the  E&M coding based rates was postponed. – What went well – simplification of gathering  patient information. 38
  39. 39. 6. Learning (contd.)• Single Point Lesson Learnt? • Innovation of the current medical documentation to incorporate E&M coding requirements led to regulatory compliance, better documentation and greatly increased revenues. REPLICATION• Replication of the same documentation methodology was implemented across 3 hospitals under NMC healthcare 39
  40. 40. 6. Learning (contd.)What would you do differently  the next time you do a similar project?• We would try to implement it in an e‐format right from the  beginning.  40
  41. 41. 7. Way Forward• How were the team members recognized? – Coding accuracy was included as one of the  criteria for judging the best department. – Certificates were distributed to the trainers and  best departments. 41
  42. 42. 7. Way Forward (contd.)• Future development of the idea or using the same  idea in different applications – Nursing e‐documentation. – Quality e‐documentation. – Infection control e‐documentation. – Operation theatre e‐documentation. – Day care e‐documentation. – Observation e‐documentation. 42
  43. 43. Q & A 43
  44. 44. Thank You 44

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