Naomi Goshen, Frances Nachmani, Nadine Sasson, Tzipi Itzchak, J. Sayfan,
D. Kopelman, L. Kolton, L. Vigder, D. Almog, and T. Tiosano
The need for accurate and complete records pertaining to operative procedures and diagnoses in surgery wards is almost self-evident. It is so because human life issues are at stake and erroneous and incomplete documentation may harm follow-up treatment as well as research data.1,2,3 However, maintaining accurate and complete records is also critical for managing efficient billing processes, with the focus of this article being on the latter.
At the beginning of the 1990s, the Israeli Ministry of Health introduced a new policy of billing hospitalization costs based on the DRG system used in the US. The new policy required hospitals to charge a fixed cost per hospitalization day or, when applicable, a "differential" charge for a list of surgical procedures that were pre-defined exclusively in a "differential list" published by the Ministry of Health. The Ministry of Health assigned codes to these selected operations that were interfaced to the ICD-9-CM codes.
This change prompted the Health Information Management (HIM) department of the Haemek Medical Center to embark on a process to increase the credibility and quality of health records. The process was not easy, requiring development of strategies in to overcome resentment by physicians to administrative tasks and management's reluctance to allocate more resources into the coding process, as also noted by R. Russo in her recent article.4
In the process of adapting to the change, we found that erroneous and incomplete documentation starts a chain of faulty events that affect many areas--for example, quality assessment of medical services and treatment, data for medical studies, statistics, financing, and patient follow-up care. However, the most powerful effect was found in the area of invoicing. Due to our efforts, it was possible to identify some 9.5 million NIS ($2.3 million) of lost hospital revenue between the years 2001-2003.
At present, the Israeli hospital market is entirely public and uncompetitive in its nature. Until the introduction of the new billing policy in the '90s, the hospital billing system was very simple: Count the number of hospitalization days and multiple them by a fixed rate per day that was determined by the government. This, in turn, placed the importance of medical documentation solely in the realm of medical interests. The new billing policy shifted some attention to the financial aspects of HIM.
The internal documentation system, however, was not equipped to take on the enormous task of identifying "differential" operations in a timely and accurate manner. Lack of automation tools as well as inadequate internal processes coupled with physicians' attitudes towards administrative tasks, presented major difficulties to our team. While the hospital management had started the process of computerizing medical information, the coding staff tried to motivate physicians to collaborate on the task of improving the quality and accuracy of the coding process.
The guidelines of the World Health Organization and the Israeli Ministry of Health (Bulletin 29/2000)5 for HIM form the foundation for the methodology used in coding medical data. The WHO guidelines place the responsibility for determining the substance of the procedures on the attending physician and the responsibility of coding the procedure on the coding staff, according to the international codes (ICD-9-CM). This was clarified by the Israeli Ministry of Health bulletin of 2000 when, for the first time, it was officially recognized in Israel that it is the role and duty of the coding staff to reach a final decision regarding recording the medical data.
Quality assessment of medical documentation was obtained from several sources: surgical logs, the computerized health record system, and the health file. As our focus was to identify "differential" operations in a timely and accurate manner, the primary source of information for that purpose should be the surgical log.
In theory, once the medical data is documented by the physician in the handwritten surgical log, the coding staff's role is to code the procedure in a precise linguistic form that matches the definitions of the computerized patient's administrative system (ATD [admission, transfer, discharge]) that is interfaced to the local operating theater computer system and assigns the correct pricing of the procedure for billing purposes. In practice, however, we found that the surgical log was incomplete when compared to the final surgical report that entered the patient's health file. Consequently, the ATD system did not include all the "differential" procedures that were billable, resulting in lost revenue for the hospital.
Following initial assessment, we identified two major issues that had caused the discrepancies between the handwritten surgical log and the operation report that entered the patient's health file. The first issue was that physicians in the operating theater were unaware of the critical role of detailing the procedures into differential items (DIs) (billable), and they often used general descriptions. The following three examples demonstrate this assertion.
- The entry in the surgical log read: Thrombectomy, which is not a DI. The surgeon, in fact, performed Thrombectomy followed by anastomosis with Dacron patch, which is a DI with a price tag of 36,292 NIS (nearly $8,000). (See Table 1).
Table 1. Translation of Section of Differential List Related to Vascular Procedures
Codes according to Differential Group Number: 10035 - Vascular operations
Repair of blood vessel with tissue patch graft
Repair of blood vessel with synthetic patch graft
Repair of blood vessel with unspecified type of patch graft
Other repair of vessel
- The surgeon wrote both in the surgical log and the operation report Ileotransversanastomosis, which is a DI with a price tag of 14,000 NIS (nearly $3,200). However, on examination in detail of the operating report, it became apparent that this operation included several procedures: partial resection small intestine, partial resection large intestine (enterocolectomy), small to large intestinal anastomosis, and lysis of peritoneal adhesions. The enterocolectomy is also a DI with a price tag of 26,100 NIS (nearly $6,000).
- In the surgical log, the surgeon wrote Colostomy , which has a DI price tag of 14,000 NIS (nearly $3,200). However, on checking the operation report it was discovered that Loop Colostomy had been performed, with a DI price tag of 26,100 NIS (nearly $6,000).
The second issue was physicians' notorious handwriting style that is often unreadable.
Strategies to Overcome the Discrepancies
Obviously, these two issues have an impact in all HIM areas beyond the distinction between differential and non-DIs. Therefore, solving the specific differential issue would benefit the overall process of coding medical information. Hence, a need for an overall strategy that would advance physicians' awareness and collaboration became evident.
Our first strategy was to convince the hospital management to impose new regulations on the physicians, stating that the coding staff would guide the coding process. Several meetings were held in various forums with the hospital's deputy director, health information manager and the coding staff, and surgical management and physicians, but they all turned out to be futile. The physicians could not accept the idea that a coder could criticize, not to mention overrule, a physician's entry.
It became apparent that to achieve results, a change in strategy was required--with the need to win the hearts, rather than the minds, of the physicians. In other words, we needed to ask ourselves what physicians care about. To find out the answer to this question, we had to recruit a senior physician to our side and turn him into a stakeholder as physicians relate well to each other professionally. Finally, we managed to mobilize the deputy director of the surgical department as our ally.
With our newly recruited stakeholder's supervision and advice, an additional meeting, on a more limited basis, with the director of the medico-legal subdivision, deputy director of the surgical department, director of HIM and the surgical files' coder, was held. This time we appealed to that which is important to physicians: their patients, their reputation, and avoiding malpractice allegations, rather than just procedural deficiencies. We also included a detailed presentation of the inconsistencies found . At the end of this meeting, it was agreed to hold routine monthly meetings between the deputy director of the surgical department and the coder assigned to that specific surgical department in order to address all problems encountered.
As improving physicians' handwriting is seemingly impossible, the strategy we chose was to install, as an interim solution, a new software package in the surgical arena (ORION system) so that entries could be keyed in at the operating theater, rather than be handwritten.
Finally, we were ready to embark on the real task of improving the quality of HIM in our organization in general, and specifically, identify and code all the DIs that were performed in the surgical wards.
Although we were successful in gaining the attention and support of management and the medical staff to the needs of the HIM department, we had yet to prove that all this was worthwhile. The first decision we made to show meaningful results in the year 2001, was to rely upon the surgical report in the patient's file rather than the surgical log. As demonstrated earlier, the patient's file proved to be more reliable and complete.
Sourcing the data from patients' files turned out to be a tedious job, because we had to chase the files through the different wards. Since the hospital management did not agree to allocate more human resources to meet the extra workload, the decision was to focus our efforts on those operations that according to the surgical log had, to our best judgment, had the potential of having unrecorded DIs.
The results were astonishing by every standard. As shown in the following graphs, over the first year of the process (2001), we identified 294 DIs that otherwise would have been lost revenue, totaling NIS 4.4 million ($1.1 million) or 11.6 percent of the total DI surgical revenue. Over the following year (2002), we identified 272 DIs, totaling NIS 3.4 million ($0.8 million) representing 9.4 percent. In 2003, we identified 194 DIs, totaling NIS 1.7 million ($0.45 million) representing 4.3 percent (Graph 1)
Graph 2 shows the monthly average of DI income retrieved as a result of quality assessment, including the first quarter of 2004.
In total, between the years 2001-2003, we increased hospital revenue by NIS 9.5 million ($2.3 million) that otherwise would have been lost revenue, or 8.7 percent of the total DI surgical revenue. Besides this evident achievement, one can learn of the effectiveness of our efforts in improving the quality of HIM as demonstrated by the substantial decrease in the number of deficiencies since the beginning of our process in 2001, from 294 cases down to 194 cases in 2003 (Graph 3) ( p value= <0.0001). Graph 4 shows a continuous decrease in the monthly average of deficiencies found in DI documentation including the first quarter of 2004.
There is still a lot to be done in to optimize HIM in our organization. We have managed to improve the quality of the process of coding medical information significantly, without using any additional resources, software or human personnel, simply by enhancing collaboration between the medical staff and the coding staff, and by focusing our efforts on a particular issue arising from the change in billing policy imposed by the Israeli government.
Nevertheless, in the future, hospitals in Israel could well be managed as profit and loss centers with all medical activities becoming DIs. Every procedure, starting from doctors' calls through laboratories and tests and to operations, could have a price tag attached to them. In order to succeed in the face of this possible competitive environment, Israeli hospitals will need to develop a comprehensive, accurate, and efficient coding system, and adequate resources should be allocated in order to achieve this goal.
Seizing the opportunity to win the hearts of the physicians and gain their collaboration, deploying management's natural interest in recovering lost revenue, coupled with dedicated and devoted coders, were the keys to the successful results we have achieved. However, these are only the first steps in a long march to improve the quality of the process for the benefit of other areas.
- Watzlaf VJL, Lares D. "How HIM can ease the pain of medical errors." Journal of AHIMA 37: 37-44, 2002.
- MacDonald E. "Better coding through improved documentation: Strategies for the current environment." Journal of AHIMA 70: 32-35, 1999.
- Clark JS. "Mastering the information management standards." Journal of AHIMA 71: 45-47, 2000.
- Russo R. "The power of persuasion. Proven strategies inspire physicians to improve documentation." Journal of AHIMA 74: 29-33, 2003.
- Coding of Medical Information: Coding of diagnosis and operations--work instructions. I. Berlovitz: Circular from Israel Ministry of Health No.: 29/2000.
We would like to thank M. Arbel for his editorial assistance with preparation of the manuscript and Ola Ghrayib for her assistance with the methodology and statistics.
About the Authors
Naomi Goshen, Frances Nachmani, Nadine Sasson, and Tzipi Itzchak are coding staff members in the Medical Information Management Department at Haemek Medical Center, Afula, Israel. J. Sayfan, D. Kopelman, L. Kolton, are members of the Department of Surgery "A," and L. Vigder is a member of the Department of Surgery "B." D. Almog and T. Tiosano D. are Deputy Medical Directors.
|Source: 2004 IFHRO Congress & AHIMA Convention Proceedings, October 2004|