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The Impact of Documentation on Medicare and Medicaid Reimbursement of Subspecialty Urology in the Era of Health Care Reform
urologypracticejournal.com
The Impact of Documentation on Medicare and Medicaid Reimbursement of Subspecialty Urology in the Era of Health Care Reform Bradley C. Gill,* Hans C. Arora, James C. Ulchaker and Sandip P. Vasavada From the Department of Urology, Glickman Urological and Kidney Institute (BCG, HCA, JCU, SPV), Cleveland Clinic Lerner College of Medicine at Case Western Reserve University (BCG, JCU, SPV) and Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic (BCG), Cleveland, Ohio
Abstract
Abbreviations and Acronyms
Introduction: As health care reform is ongoing, reimbursement will continually be increasingly scrutinized and decreased despite growing numbers of patients with comorbid medical conditions. This study determined the impact of inpatient comorbidity documentation on hospital reimbursement in a female pelvic medicine and reconstructive surgery group. Methods: Departmental financial records from 2011 to 2012 were reviewed. All admissions by 4 female pelvic medicine and reconstructive surgeons at a tertiary referral center were collected. All DRG (Diagnosis Related Group) codes of pathological conditions specific to males, stones and nonsubspecialty issues were excluded from analysis. Using CMS (Centers for Medicare and Medicaid Services) reimbursement rates the effects of documenting and coding comorbidities or complications were determined. Geographic multipliers were excluded. The study objective was to determine the impact of inpatient documentation on hospital reimbursement from a urological subspecialty group.
CC = comorbidity or complication FPMRS = female pelvic medicine and reconstructive surgery MCC = major CC
Results: Each of 4 surgeons admitted an average of 29 inpatients per year of whom 29% had a comorbidity or complication documented. Mean reimbursement was $3,486 greater for cases with versus without a coded comorbidity or complication. This resulted in an additional $31,374 of reimbursement annually per surgeon or $125,496 for the group. Conclusions: Documenting comorbidities and complications in urology patients appropriately results in a substantial increase in reimbursement. Care should be taken by urologists to accurately note comorbid medical conditions. This is especially crucial as health care reform continues and growing numbers of patients present with chronic disease while reimbursement is further scrutinized and decreased. Key Words: urology; Patient Protection and Affordable Care Act; insurance, health, reimbursement; documentation; comorbidity
Submitted for publication April 14, 2015. No direct or indirect commercial incentive associated with publishing this article. The corresponding author certifies that, when applicable, a statement(s) has been included in the manuscript documenting institutional review board, ethics committee or ethical review board study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee approval; 2352-0779/16/33-175/0 UROLOGY PRACTICE Ó 2016 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
institutional animal care and use committee approval; all human subjects provided written informed consent with guarantees of confidentiality; IRB approved protocol number; animal approved project number. * Correspondence: Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine, Education Institute, Cleveland Clinic, 9500 Euclid Ave., Q10-1, Cleveland, Ohio 44195 (telephone: 216-445-7242; FAX: 216-445-2267; e-mail address: [email protected]).
RESEARCH, INC.
http://dx.doi.org/10.1016/j.urpr.2015.07.004 Vol. 3, 175-179, May 2016 Published by Elsevier
176
Impact of Documentation on Reimbursement
In the current era of health care reform urologists are increasingly treating patients with substantial comorbidities that prolong hospitalization and increase the risk of complications. In light of these factors urologists continue to face decreasing reimbursement for the care provided due to the decreasing valuation of procedures and specialty care. Furthermore payment is soon to be reduced further by penalties implemented with meaningful use of (the electronic medical record systems) portions of the PPACA (Patient Protection and Affordable Care Act).1 In addition as the obesity epidemic continues the lengthening lists of comorbid medical conditions and associated complications will predispose patients to further care needs. Eventually these additional services will not be reimbursed and will likely carry added financial penalties for providers.2e5 Considering this, it is crucial that urologists be reimbursed for the additional management that these conditions require above and beyond that for the urological care that they provide. Thus recognizing comorbidities and giving them due attention through proper documentation will be of critical importance because of the necessity to identify illness severity for billing and resultant payer reimbursement.6 While not all urological subspecialties consistently generate a substantial inpatient census, even those that have lower rates of hospital admissions can be impacted by the ongoing and upcoming changes mentioned. This study assessed the effects of documenting comorbidities and complications, and its impact on Medicare and Medicaid hospital reimbursement from a FPMRS subspecialty urology practice.
Materials and Methods
After receiving institutional review board approval for exemption we extracted basic coding and reimbursement data on all 2011 and 2012 inpatient admissions of 4 FPMRS urologists from departmental business records at a large tertiary academic referral center. The list was limited to female patients by eliminating male specific codes and further restricted to identify subspecialty specific hospitalizations by eliminating stones, sepsis and other unrelated diagnoses. All CMS DRG codes and the national base rate of reimbursement of each were then recorded for the admissions. Geographic multipliers were excluded. The presence of a CC or a MCC was noted. The DRG code with or without a CC or a MCC defines the level of billing for services provided based on illness severity. This then ultimately determines the hospital reimbursement provided by the payer.
No protected patient information was collected. Lists of common CCs and MCCs were compiled in conjunction with coding and reimbursement specialists (Appendix 1). Using the documented federal reimbursement rates the absolute range of reimbursement across pertinent DRG codes was determined, as were the absolute and relative changes in amount based on CC or MCC designation (tables 1 and 2). Using the collected data mean reimbursement across all admissions with a CC or a MCC was compared to that of the base DRG rate. The difference between the 2 values was taken with the average number of admissions in which CCs or MCCs were coded to determine the effect of documentation on reimbursement. At the study institution a separate division of documentation and coding compliance specialists review medical records to ensure that the care provided is accurately accounted for and documented. As a result the accuracy of CC and MCC assignments, and their subsequent rates across all admissions are believed to be highly accurate.
Results
The number of annual hospital admissions in 2011 and 2012 ranged from 11 to 59 (mean 29) per surgeon, of which 14% to 44% (mean 29%) had CCs or MCCs documented. Reimbursement varied from $3,495 to $15,580 (mean $7,590) across all codes (with vs without CC or MCC $8,731 vs $5,245) (table 1). Taking this into account each FPMRS urologist generated an average of an additional $3,486 of hospital reimbursement per admission if CCs or MCCs were coded. This resulted in an additional $31,374 per year from each surgeon or $125,496 from the group (Appendix 2).
Discussion
As health care reform continues, reimbursement will be further scrutinized and likely reduced overall despite an increasing number of patients with concomitant chronic medical conditions requiring treatment.1 As such documenting baseline comorbid medical conditions becomes increasingly important so that reimbursement for the extra services needed to manage these conditions is obtained.7 Many of these patients require additional treatment to receive appropriate care and proper documentation can be the necessary step toward suitable recognition and subsequent compensation for the services provided.8 As Campbell et al found in a study of 249 patients undergoing spine surgery at a large academic tertiary care center, the existence of preoperative comorbidities strongly
Impact of Documentation on Reimbursement
Table 1. CMS reimbursement rate applicable codes and 2011 to 2012 annual FPMRS urologist coding reimbursement Code
Mean $ (range)
All Base rate CC MCC FPMRS: All Base rate CC or MCC
8,960 5,450 8,152 13,706
(3,314e30,706) (3,414e10,416) (4,980e15,580) (6,898e30,706)
7,590 (3,495e15,580) 5,245 (3,495e10,416) 8,731 (4,980e5,580)
correlated with perioperative complications.2 This underscores the need for appropriate documentation when managing preexisting comorbid conditions since the resultant reimbursement offsets the increased costs of caring for the complications to which comorbidities predispose patients. Thus it should be recognized that the viability of practices may soon depend on careful documentation. Female pelvic medicine and reconstructive surgery is a urological subspecialty that largely comprises same day surgery and outpatient procedures. As such surgeons practicing in this area admit a relatively low number of inpatients compared to those in urological oncology, for instance. Investigating the impact of comorbidity and complications on reimbursement patterns in FPMRS has shown that even with a lower proportion of inpatient admissions a substantial impact on reimbursement occurs as a result of documenting comorbidities that are being actively managed in patients. Overall this can potentially cover the additional expenses involved in providing this extra care, helping maintain a financially sound practice. An important consideration in this study is that the DRG system assessed relates to hospital or health care system reimbursement and not to that of the individual practice or practitioner. Individual reimbursement is determined in part by billing encounters at appropriate CMS E/M (evaluation and management) levels. Billing encounters are then factored into RVUs (relative value units), which ultimately determine payment for services provided. A similar consideration applies to the use of Modifier 22 on AMS (American Medical Association) CPT codes for procedures
Table 2. Examples of CMs reimbursement differences Code
CC or MCC
Absolute ($)
Relative %
664 670 655 700
CC MCC MCC CC
2,010 8,171 20,290 1,566
35 197 194 46
177
for which work to provide a service is “substantially greater than typically required” for a procedure. Therefore accurate documentation that identifies a CC or a MCC indicating a higher severity of illness will lead to increased health system reimbursement, which can then appropriately be directed to practitioners based on their documentation of increased services provided. This study highlights an important consideration in the ongoing era of health care reform, that is the appropriate recognition of comorbid medical conditions.9 Because reimbursement will soon be tied not only to outcomes but also to the meaningful use of electronic medical record systems, there are not only indirect but also direct financial consequences for addressing concomitant medical conditions. As the chronic disease burden continues to escalate, the cost of caring for patients will rise as related complications of surgery, for example those secondary to diabetes or obesity, become more common.10 Thus it is paramount for urologists to identify, manage and document the care provided for patient baseline medical conditions that can subject them to more prolonged and complex postoperative courses. The transition from ICD-9 to ICD-10 will inherently bring about more detailed documentation and coding as a result of the focus that it places on the etiology of conditions and the acknowledgement of comorbidities. While it was not prospectively evaluated in the current study, improving documentation has been shown to have additional benefits beyond increasing reimbursement for services provided, such as improving the prediction of perioperative complications and CMS “never event” occurrences. In a 2012 study of 18,923 surgical patients in Taiwan a preoperative diagnosis of dementia was tied to a higher postoperative complication rate, increased hospital length of stay and delayed recognition of other diagnoses such as acute renal failure, pneumonia, sepsis and urinary tract infections.11 In a 2013 study by Joice et al using the NIS (Nationwide Inpatient Sample) database of 61,142 patients undergoing radical cystectomy for bladder cancer from 2002 to 2009 preexisting comorbidities were associated not only with an increase in CMS “never events” but also with increased hospital length of stay, in-hospital mortality and total hospital costs.12 The strengths of this study include use of a robust data set comprising data from 4 subspecialty FPMRS urologists as well as the use of base federal reimbursement rates, which are applicable to all centers providing services to Medicare and Medicaid patients. It should be noted that the center specific or geographic reimbursement multiplier, which takes into account regional cost variations, was excluded from all calculations.
178
Impact of Documentation on Reimbursement
Additionally the exclusion of nonsubspecialty specific admissions from the data set further supports the aim of this study by limiting its findings to a subspecialty area with relatively few inpatient admissions. Limitations of this study include the use of departmental financial records, which may potentially result in the inclusion of nonsubspecialty specific inpatient admissions in the data set. In addition, inherent selection bias exists as the data were drawn only from a single tertiary care center in a specific region of the United States. Furthermore, since the direct costs of health care provided are difficult to determine, the study provides only a payer perspective, which provides only partial insight into the impact on the financial sustainability of a practice. Lastly the use of modeling to arrive at the conclusions of this study, like any economic analysis, subject the results and interpretation to the necessary assumptions made in carrying out the calculations. Moving forward the next logical step would be to assess methods to improve the documentation of comorbid medical conditions upon admission and during the inpatient stay. As is common in large academic medical centers most primary documentation by health care providers in this study was performed by house staff. A pilot study using an educational intervention (a 5-hour lecture) across a variety of medical and surgical specialties was unsuccessful at improving the documentation of various diagnoses.13 However this study included only 19 house staff and did not address the need for longitudinal intervention in this complex issue. Other efforts have more successfully addressed the issue from a system standpoint by providing a pocket reference for documentation in internal medicine or developing a template for daily surgical progress notes.14,15 Elsewhere a compliance program for internal medicine faculty at an academic institution resulted in increased billing compliance and gross collection rates for inpatient services.16 These studies emphasize the need to implement multimodal and longitudinal approaches to improve documentation, which involve all parties, including hospital administration, information technology services, academic faculty and house staff alike.
the population of patients with chronic medical conditions grows.
Appendix 1. CCs and MCCs CCs
MCCs
Alcohol withdrawal Dementia Bipolar disorder Paralysis Stroke Atrial flutter Chronic heart failure Embolism/thrombus Unstable angina Acidosis/alkalosis Acute kidney injury Cachexia/malnutrition Body mass index less than 19 kg/m2 Body mass index greater than 40 kg/m2 Ileus Bowel obstruction Metastasis Colitis/Crohn’s disease Infection/cellulitis/wound disruption Pyelonephritis/urinary tract infection Atelectasis Chronic respiratory failure Chronic obstructive pulmonary disease Chronic kidney disease/cystic kidney disease Hydronephrosis Nephrotic syndrome
Encephalopathy Myocardial infarction Acute heart failure Shock Severe malnutrition Human immunodeficiency virus Pneumonia Sepsis Disseminated intravascular coagulation Pulmonary embolism Respiratory insufficiency Acute respiratory failure Pressure ulcer (stage 3e4) Acute tubular necrosis End stage renal disease
Appendix 2. Estimated Effect of Coding CC or MCC on Annual FPMRS Urologist Reimbursement Difference Between Average Base Rate and Average CC or MCC Rate: $8,731 e $5,245 ¼ $3,486 Annual Admissions with CC or MCC Coding: Average 29 Admissions Average 29% CC or MCC Rate z 9 Admissions Additional Annual Reimbursement per Surgeon from CC or MCC Documentation: 9 CCs or MCCs Admissions per Year $3,486 per Admission ¼ $31,374 per Year Overall Additional Annual Reimbursement: 4 Surgeons $31,374 per Year ¼ $125,496 per Year
Conclusions
Documenting comorbid medical conditions for urology inpatients results in appropriately increased reimbursement for extra services provided. Care should be taken by urologists to specifically document chronic medical conditions as well as complicating issues with hospitalizations. This will be increasingly essential for practice viability as new health care reforms are continually implemented and
References 1. DesRoches CM, Worzala C and Bates S: Some hospitals are falling behind in meeting ‘meaningful use’ criteria and could be vulnerable to penalties in 2015. Health Aff (Millwood) 2013; 32: 1355. 2. Campbell PG, Yadla S, Nasser R et al: Patient comorbidity score predicting the incidence of perioperative complications: assessing
Impact of Documentation on Reimbursement
the impact of comorbidities on complications in spine surgery. J Neurosurg Spine 2012; 16: 37. 3. Ogden CL, Carroll MD, Kit BK et al: Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014; 311: 806. 4. Kremers HM, Visscher SL, Kremers WK et al: The effect of obesity on direct medical costs in total knee arthroplasty. J Bone Joint Surg Am 2014; 96: 718. 5. Banerji MA and Dunn JD: Impact of glycemic control on healthcare resource utilization and costs of type 2 diabetes: current and future pharmacologic approaches to improving outcomes. Am Health Drug Benefits 2013; 6: 382. 6. Fleschler RG, Knight SA and Ray G: Severity and risk adjusting relating to obstetric outcomes, DRG assignment, and reimbursement. J Obstet Gynecol Neonatal Nurs 2001; 30: 98. 7. Ballentine NH: Coding and documentation: Medicare severity diagnosis-related groups and present-on-admission documentation. J Hosp Med 2009; 4: 124. 8. Fillit H, Geldmacher DS, Welter RT et al: Optimizing coding and reimbursement to improve management of Alzheimer’s disease and related dementias. J Am Geriatr Soc 2002; 50: 1871. 9. Pre-billing review will improve mortality index. Hosp Case Manag 2011; 19: 91.
179
10. Maradit Kremers H, Visscher SL, Kremers WK et al: Obesity increases length of stay and direct medical costs in total hip arthroplasty. Clin Orthop Relat Res 2014; 472: 1232. 11. Hu CJ, Liao CC, Chang CC et al: Postoperative adverse outcomes in surgical patients with dementia: a retrospective cohort study. World J Surg 2012; 36: 2051. 12. Joice GA, Deibert CM, Kates M et al: “Never events”: Centers for Medicare and Medicaid Services complications after radical cystectomy. Urology 2013; 81: 527. 13. Farzandipour M, Meidani Z, Rangraz Jeddi F et al: A pilot study of the impact of an educational intervention aimed at improving medical record documentation. J R Coll Physicians Edinb 2013; 43: 29. 14. Spellberg B, Harrington D, Black S et al: Capturing the diagnosis: an internal medicine education program to improve documentation. Am J Med 2013; 126: 739. 15. Grogan EL, Speroff T, Deppen SA et al: Improving documentation of patient acuity level using a progress note template. J Am Coll Surg 2004; 199: 468. 16. Miller DD and Getsey CL: Impact of a compliance program for billing on internal medicine faculty’s documentation practices and productivity. Acad Med 2001; 76: 266.
The Impact of Documentation on Medicare and Medicaid Reimbursement of Subspecialty Urology in the Era of Health Care Reform Bradley C. Gill,* Hans C. Arora, James C. Ulchaker and Sandip P. Vasavada From the Department of Urology, Glickman Urological and Kidney Institute (BCG, HCA, JCU, SPV), Cleveland Clinic Lerner College of Medicine at Case Western Reserve University (BCG, JCU, SPV) and Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic (BCG), Cleveland, Ohio
Abstract
Abbreviations and Acronyms
Introduction: As health care reform is ongoing, reimbursement will continually be increasingly scrutinized and decreased despite growing numbers of patients with comorbid medical conditions. This study determined the impact of inpatient comorbidity documentation on hospital reimbursement in a female pelvic medicine and reconstructive surgery group. Methods: Departmental financial records from 2011 to 2012 were reviewed. All admissions by 4 female pelvic medicine and reconstructive surgeons at a tertiary referral center were collected. All DRG (Diagnosis Related Group) codes of pathological conditions specific to males, stones and nonsubspecialty issues were excluded from analysis. Using CMS (Centers for Medicare and Medicaid Services) reimbursement rates the effects of documenting and coding comorbidities or complications were determined. Geographic multipliers were excluded. The study objective was to determine the impact of inpatient documentation on hospital reimbursement from a urological subspecialty group.
CC = comorbidity or complication FPMRS = female pelvic medicine and reconstructive surgery MCC = major CC
Results: Each of 4 surgeons admitted an average of 29 inpatients per year of whom 29% had a comorbidity or complication documented. Mean reimbursement was $3,486 greater for cases with versus without a coded comorbidity or complication. This resulted in an additional $31,374 of reimbursement annually per surgeon or $125,496 for the group. Conclusions: Documenting comorbidities and complications in urology patients appropriately results in a substantial increase in reimbursement. Care should be taken by urologists to accurately note comorbid medical conditions. This is especially crucial as health care reform continues and growing numbers of patients present with chronic disease while reimbursement is further scrutinized and decreased. Key Words: urology; Patient Protection and Affordable Care Act; insurance, health, reimbursement; documentation; comorbidity
Submitted for publication April 14, 2015. No direct or indirect commercial incentive associated with publishing this article. The corresponding author certifies that, when applicable, a statement(s) has been included in the manuscript documenting institutional review board, ethics committee or ethical review board study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee approval; 2352-0779/16/33-175/0 UROLOGY PRACTICE Ó 2016 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
institutional animal care and use committee approval; all human subjects provided written informed consent with guarantees of confidentiality; IRB approved protocol number; animal approved project number. * Correspondence: Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine, Education Institute, Cleveland Clinic, 9500 Euclid Ave., Q10-1, Cleveland, Ohio 44195 (telephone: 216-445-7242; FAX: 216-445-2267; e-mail address: [email protected]).
RESEARCH, INC.
http://dx.doi.org/10.1016/j.urpr.2015.07.004 Vol. 3, 175-179, May 2016 Published by Elsevier
176
Impact of Documentation on Reimbursement
In the current era of health care reform urologists are increasingly treating patients with substantial comorbidities that prolong hospitalization and increase the risk of complications. In light of these factors urologists continue to face decreasing reimbursement for the care provided due to the decreasing valuation of procedures and specialty care. Furthermore payment is soon to be reduced further by penalties implemented with meaningful use of (the electronic medical record systems) portions of the PPACA (Patient Protection and Affordable Care Act).1 In addition as the obesity epidemic continues the lengthening lists of comorbid medical conditions and associated complications will predispose patients to further care needs. Eventually these additional services will not be reimbursed and will likely carry added financial penalties for providers.2e5 Considering this, it is crucial that urologists be reimbursed for the additional management that these conditions require above and beyond that for the urological care that they provide. Thus recognizing comorbidities and giving them due attention through proper documentation will be of critical importance because of the necessity to identify illness severity for billing and resultant payer reimbursement.6 While not all urological subspecialties consistently generate a substantial inpatient census, even those that have lower rates of hospital admissions can be impacted by the ongoing and upcoming changes mentioned. This study assessed the effects of documenting comorbidities and complications, and its impact on Medicare and Medicaid hospital reimbursement from a FPMRS subspecialty urology practice.
Materials and Methods
After receiving institutional review board approval for exemption we extracted basic coding and reimbursement data on all 2011 and 2012 inpatient admissions of 4 FPMRS urologists from departmental business records at a large tertiary academic referral center. The list was limited to female patients by eliminating male specific codes and further restricted to identify subspecialty specific hospitalizations by eliminating stones, sepsis and other unrelated diagnoses. All CMS DRG codes and the national base rate of reimbursement of each were then recorded for the admissions. Geographic multipliers were excluded. The presence of a CC or a MCC was noted. The DRG code with or without a CC or a MCC defines the level of billing for services provided based on illness severity. This then ultimately determines the hospital reimbursement provided by the payer.
No protected patient information was collected. Lists of common CCs and MCCs were compiled in conjunction with coding and reimbursement specialists (Appendix 1). Using the documented federal reimbursement rates the absolute range of reimbursement across pertinent DRG codes was determined, as were the absolute and relative changes in amount based on CC or MCC designation (tables 1 and 2). Using the collected data mean reimbursement across all admissions with a CC or a MCC was compared to that of the base DRG rate. The difference between the 2 values was taken with the average number of admissions in which CCs or MCCs were coded to determine the effect of documentation on reimbursement. At the study institution a separate division of documentation and coding compliance specialists review medical records to ensure that the care provided is accurately accounted for and documented. As a result the accuracy of CC and MCC assignments, and their subsequent rates across all admissions are believed to be highly accurate.
Results
The number of annual hospital admissions in 2011 and 2012 ranged from 11 to 59 (mean 29) per surgeon, of which 14% to 44% (mean 29%) had CCs or MCCs documented. Reimbursement varied from $3,495 to $15,580 (mean $7,590) across all codes (with vs without CC or MCC $8,731 vs $5,245) (table 1). Taking this into account each FPMRS urologist generated an average of an additional $3,486 of hospital reimbursement per admission if CCs or MCCs were coded. This resulted in an additional $31,374 per year from each surgeon or $125,496 from the group (Appendix 2).
Discussion
As health care reform continues, reimbursement will be further scrutinized and likely reduced overall despite an increasing number of patients with concomitant chronic medical conditions requiring treatment.1 As such documenting baseline comorbid medical conditions becomes increasingly important so that reimbursement for the extra services needed to manage these conditions is obtained.7 Many of these patients require additional treatment to receive appropriate care and proper documentation can be the necessary step toward suitable recognition and subsequent compensation for the services provided.8 As Campbell et al found in a study of 249 patients undergoing spine surgery at a large academic tertiary care center, the existence of preoperative comorbidities strongly
Impact of Documentation on Reimbursement
Table 1. CMS reimbursement rate applicable codes and 2011 to 2012 annual FPMRS urologist coding reimbursement Code
Mean $ (range)
All Base rate CC MCC FPMRS: All Base rate CC or MCC
8,960 5,450 8,152 13,706
(3,314e30,706) (3,414e10,416) (4,980e15,580) (6,898e30,706)
7,590 (3,495e15,580) 5,245 (3,495e10,416) 8,731 (4,980e5,580)
correlated with perioperative complications.2 This underscores the need for appropriate documentation when managing preexisting comorbid conditions since the resultant reimbursement offsets the increased costs of caring for the complications to which comorbidities predispose patients. Thus it should be recognized that the viability of practices may soon depend on careful documentation. Female pelvic medicine and reconstructive surgery is a urological subspecialty that largely comprises same day surgery and outpatient procedures. As such surgeons practicing in this area admit a relatively low number of inpatients compared to those in urological oncology, for instance. Investigating the impact of comorbidity and complications on reimbursement patterns in FPMRS has shown that even with a lower proportion of inpatient admissions a substantial impact on reimbursement occurs as a result of documenting comorbidities that are being actively managed in patients. Overall this can potentially cover the additional expenses involved in providing this extra care, helping maintain a financially sound practice. An important consideration in this study is that the DRG system assessed relates to hospital or health care system reimbursement and not to that of the individual practice or practitioner. Individual reimbursement is determined in part by billing encounters at appropriate CMS E/M (evaluation and management) levels. Billing encounters are then factored into RVUs (relative value units), which ultimately determine payment for services provided. A similar consideration applies to the use of Modifier 22 on AMS (American Medical Association) CPT codes for procedures
Table 2. Examples of CMs reimbursement differences Code
CC or MCC
Absolute ($)
Relative %
664 670 655 700
CC MCC MCC CC
2,010 8,171 20,290 1,566
35 197 194 46
177
for which work to provide a service is “substantially greater than typically required” for a procedure. Therefore accurate documentation that identifies a CC or a MCC indicating a higher severity of illness will lead to increased health system reimbursement, which can then appropriately be directed to practitioners based on their documentation of increased services provided. This study highlights an important consideration in the ongoing era of health care reform, that is the appropriate recognition of comorbid medical conditions.9 Because reimbursement will soon be tied not only to outcomes but also to the meaningful use of electronic medical record systems, there are not only indirect but also direct financial consequences for addressing concomitant medical conditions. As the chronic disease burden continues to escalate, the cost of caring for patients will rise as related complications of surgery, for example those secondary to diabetes or obesity, become more common.10 Thus it is paramount for urologists to identify, manage and document the care provided for patient baseline medical conditions that can subject them to more prolonged and complex postoperative courses. The transition from ICD-9 to ICD-10 will inherently bring about more detailed documentation and coding as a result of the focus that it places on the etiology of conditions and the acknowledgement of comorbidities. While it was not prospectively evaluated in the current study, improving documentation has been shown to have additional benefits beyond increasing reimbursement for services provided, such as improving the prediction of perioperative complications and CMS “never event” occurrences. In a 2012 study of 18,923 surgical patients in Taiwan a preoperative diagnosis of dementia was tied to a higher postoperative complication rate, increased hospital length of stay and delayed recognition of other diagnoses such as acute renal failure, pneumonia, sepsis and urinary tract infections.11 In a 2013 study by Joice et al using the NIS (Nationwide Inpatient Sample) database of 61,142 patients undergoing radical cystectomy for bladder cancer from 2002 to 2009 preexisting comorbidities were associated not only with an increase in CMS “never events” but also with increased hospital length of stay, in-hospital mortality and total hospital costs.12 The strengths of this study include use of a robust data set comprising data from 4 subspecialty FPMRS urologists as well as the use of base federal reimbursement rates, which are applicable to all centers providing services to Medicare and Medicaid patients. It should be noted that the center specific or geographic reimbursement multiplier, which takes into account regional cost variations, was excluded from all calculations.
178
Impact of Documentation on Reimbursement
Additionally the exclusion of nonsubspecialty specific admissions from the data set further supports the aim of this study by limiting its findings to a subspecialty area with relatively few inpatient admissions. Limitations of this study include the use of departmental financial records, which may potentially result in the inclusion of nonsubspecialty specific inpatient admissions in the data set. In addition, inherent selection bias exists as the data were drawn only from a single tertiary care center in a specific region of the United States. Furthermore, since the direct costs of health care provided are difficult to determine, the study provides only a payer perspective, which provides only partial insight into the impact on the financial sustainability of a practice. Lastly the use of modeling to arrive at the conclusions of this study, like any economic analysis, subject the results and interpretation to the necessary assumptions made in carrying out the calculations. Moving forward the next logical step would be to assess methods to improve the documentation of comorbid medical conditions upon admission and during the inpatient stay. As is common in large academic medical centers most primary documentation by health care providers in this study was performed by house staff. A pilot study using an educational intervention (a 5-hour lecture) across a variety of medical and surgical specialties was unsuccessful at improving the documentation of various diagnoses.13 However this study included only 19 house staff and did not address the need for longitudinal intervention in this complex issue. Other efforts have more successfully addressed the issue from a system standpoint by providing a pocket reference for documentation in internal medicine or developing a template for daily surgical progress notes.14,15 Elsewhere a compliance program for internal medicine faculty at an academic institution resulted in increased billing compliance and gross collection rates for inpatient services.16 These studies emphasize the need to implement multimodal and longitudinal approaches to improve documentation, which involve all parties, including hospital administration, information technology services, academic faculty and house staff alike.
the population of patients with chronic medical conditions grows.
Appendix 1. CCs and MCCs CCs
MCCs
Alcohol withdrawal Dementia Bipolar disorder Paralysis Stroke Atrial flutter Chronic heart failure Embolism/thrombus Unstable angina Acidosis/alkalosis Acute kidney injury Cachexia/malnutrition Body mass index less than 19 kg/m2 Body mass index greater than 40 kg/m2 Ileus Bowel obstruction Metastasis Colitis/Crohn’s disease Infection/cellulitis/wound disruption Pyelonephritis/urinary tract infection Atelectasis Chronic respiratory failure Chronic obstructive pulmonary disease Chronic kidney disease/cystic kidney disease Hydronephrosis Nephrotic syndrome
Encephalopathy Myocardial infarction Acute heart failure Shock Severe malnutrition Human immunodeficiency virus Pneumonia Sepsis Disseminated intravascular coagulation Pulmonary embolism Respiratory insufficiency Acute respiratory failure Pressure ulcer (stage 3e4) Acute tubular necrosis End stage renal disease
Appendix 2. Estimated Effect of Coding CC or MCC on Annual FPMRS Urologist Reimbursement Difference Between Average Base Rate and Average CC or MCC Rate: $8,731 e $5,245 ¼ $3,486 Annual Admissions with CC or MCC Coding: Average 29 Admissions Average 29% CC or MCC Rate z 9 Admissions Additional Annual Reimbursement per Surgeon from CC or MCC Documentation: 9 CCs or MCCs Admissions per Year $3,486 per Admission ¼ $31,374 per Year Overall Additional Annual Reimbursement: 4 Surgeons $31,374 per Year ¼ $125,496 per Year
Conclusions
Documenting comorbid medical conditions for urology inpatients results in appropriately increased reimbursement for extra services provided. Care should be taken by urologists to specifically document chronic medical conditions as well as complicating issues with hospitalizations. This will be increasingly essential for practice viability as new health care reforms are continually implemented and
References 1. DesRoches CM, Worzala C and Bates S: Some hospitals are falling behind in meeting ‘meaningful use’ criteria and could be vulnerable to penalties in 2015. Health Aff (Millwood) 2013; 32: 1355. 2. Campbell PG, Yadla S, Nasser R et al: Patient comorbidity score predicting the incidence of perioperative complications: assessing
Impact of Documentation on Reimbursement
the impact of comorbidities on complications in spine surgery. J Neurosurg Spine 2012; 16: 37. 3. Ogden CL, Carroll MD, Kit BK et al: Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014; 311: 806. 4. Kremers HM, Visscher SL, Kremers WK et al: The effect of obesity on direct medical costs in total knee arthroplasty. J Bone Joint Surg Am 2014; 96: 718. 5. Banerji MA and Dunn JD: Impact of glycemic control on healthcare resource utilization and costs of type 2 diabetes: current and future pharmacologic approaches to improving outcomes. Am Health Drug Benefits 2013; 6: 382. 6. Fleschler RG, Knight SA and Ray G: Severity and risk adjusting relating to obstetric outcomes, DRG assignment, and reimbursement. J Obstet Gynecol Neonatal Nurs 2001; 30: 98. 7. Ballentine NH: Coding and documentation: Medicare severity diagnosis-related groups and present-on-admission documentation. J Hosp Med 2009; 4: 124. 8. Fillit H, Geldmacher DS, Welter RT et al: Optimizing coding and reimbursement to improve management of Alzheimer’s disease and related dementias. J Am Geriatr Soc 2002; 50: 1871. 9. Pre-billing review will improve mortality index. Hosp Case Manag 2011; 19: 91.
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