What is the system used as a way of classifying patient records according to common elements? ACA: The Affordable Care Act DRG: Diagnosis-related groups CAH: Critical Access Hospitals UCR: usual, customary, and reasonable
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Axis University Hospital has decided that it needs to better coordinate its patient care from the moment patients enter the hospital until they leave and return to the care of their own physicians and specialists. Its CEO and CFO have scoured the Affordable Care Act and have decided to adopt the following steps: They have developed their own model of direct contracting with local physicians groups, particularly cardiologists and oncologists, designed to promote risk-based comprehensive payments. For elderly patients with comorbidities who often seem to move between home or nursing home and the hospital, they propose a coordinated care model in which gerontologists will be paid by salary rather than fee for service. For primary care physicians in their community catchment areas, they propose patient-centered medical homes that entail the use of medical technologies for monitoring, along with extensive electronic medical records keeping. Physicians who agree to participate in such medical homes will receive bonus payments based on their adoption of a range of treatment measures. For each of the three approaches, is the arrangement a collaboration or an integration? Why? What are the theories of liability to Axis University Hospital from each approach? What should Axis University Hospital do in each of the three situations to minimize its liability?
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Examine the relationship between medical documentation, severity of illness, hospital-acquired conditions, present on admission indicators, and case mix. Provide examples to support your examination, based on POA and case mix information for Independence Hospital. Make recommendations that may impact revenue and reimbursement, based on your assessment of the information. Also, provide recommendations to educate physicians on documentation standards and educate coders on how to work with physicians during the documentation process. Present on Admission: Under the Hospital-Acquired Conditions provision, the Secretary of Health and Human Services has designated several conditions that, when acquired during a hospital admission, have the potential to reduce payment. One of these conditions is Pressure Ulcers (ICD-10-CM L89.X) codes. To determine if the pressure ulcer was present when the patient was admitted or acquired during the hospital stay, the hospital must report a present on admission code for each diagnosis on the billing form. You are working with the coding manager at Independence Hospital. The coders have been asked to apply the present on admission indicator code. The coding manager has collected data over the past six months, and it is clear from the data that there is an issue with either the documentation of pressure ulcers, assignment of the POA indicator, or the quality of care. POA Report for Pressure Ulcers (L89.X) October - March POA Code Description Volume Y Yes, present on admission 15 N No, not present on admission 30 U Unknown, insufficient documentation 45 W Clinically undetermined 3 1 Exempt from POA reporting 0 Case Mix: The Case Mix Index (CMI) is the average weight of a healthcare facility's diagnosis-related groups (MS-DRG). The higher a facility's CMI, the greater the number of high-cost services the facility performs. The more high-cost services performed, the more revenue. Steps to Calculate CMI: 1. Multiply the relative weight of each MS-DRG by the number of discharges for each MS-DRG. 2. Sum all weights to calculate the case mix. 3. Divide the case mix by the total number of patients. MS-DRG MS-DRG WEIGHT # OF DISCHARGES Renal failure w MCC 682 2.0 10 Renal failure w CC 683 1.5 10 Renal failure w/o CC/MCC 684 1.0 10
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