Customer Context
One of the largest providers of revenue cycle services partnered with Access Healthcare to optimize inpatient DRG coding, CDI services, and DRG validation for one of their healthcare clients. Access Healthcare formed a comprehensive governance and transition team to ensure a smooth shift of these processes to our global delivery locations. This team included the client's HIM leaders, facility-specific hospital staff, Access Healthcare’s experienced and certified medical coders, and clinical documentation specialists. This case study highlights the transformation of CDI and coding processes for the healthcare system client, which consists of over 40 hospitals.
Challenges
Access Healthcare was tasked with transforming CDI and coding processes for ten hospitals. The transition began with a comprehensive evaluation to assess current workflows and identify areas for improvement.
“Again, I can’t say enough on how great our relationship is and the overall success we are having while working together. I
would certainly advocate for Access to workup more accounts as their overall quality from CDI’s standpoint is superb to that of other competitors.”
Inconsistent processes: Our initial assessment uncovered that the internal HIM team faced difficulties standardizing CDI and coding procedures across facilities. We identified considerable variations in documentation practices, payer-specific guidelines, payment methodologies, and abstraction criteria.
Extended delays in DNFB cases: The facility experienced significant delays in resolving discharges not final billed (DNFB) cases. Many of these delays stemmed from DRG mismatches between the CDI and coding teams during the review process.
Absence of continuous improvement processes: Limited coordination between CDI and coding teams led to the CDI team's focus solely on prospective queries for documentation improvement. HIM leaders expressed concern over the coding team’s inability to identify retrospective query opportunities, hindering ongoing process improvements.
After thoroughly analyzing the underlying challenges, Access Healthcare’s CDI and coding leadership realized the need for a comprehensive transformation program rather than simply assigning CDI and coding resources. Our CDI leadership team implemented a strong governance framework to optimize and standardize processes.
Solutions
Seasoned team and effective audit coverage. Access Healthcare deployed highly experienced inpatient coders and clinical documentation specialists for the healthcare system, establishing a minimum of 30% audit coverage on the processes.
Addressed physician queries. Reviewed all physician queries, missed query opportunities, and DRG mismatches before routing them to the client and the hospital’s HIM team.
Created focused audit groups. Established two focused audit groups to address audit findings from four different external audit streams, i.e., Enjoin, CloudMed, EIQ, and Payor Audits. Our auditors reviewed the results of these audits and prepared materials to educate the team and reduce ongoing audit feedback.
Operational rigor to fast-track DRG mismatch reviews. Conducted a daily review of all Epic queues with respective leaders on our team to address documentation queries and follow up on them. We utilized the 3M 360 notification system to fast-track DRG mismatch reviews and reduce DNFB hold time.
Focus on knowledge improvement. CDI and coding are knowledge-oriented streams. We established robust training and evaluation processes to achieve consistently high results. We conducted weekly tests to assess the knowledge levels of our coders and CDI specialists and reviewed external and internal audit findings to identify knowledge gaps and train our team members in specific areas.
Governance. Utilized the multi-tier governance architecture with the client and facility CDI and coding leaders to discuss opportunities for stronger collaboration, gauge progress, and identify improvement opportunities.
Results
Maintained DNFB for CDI holds to less than five business days to send to billing to improve collections and accelerate cash flow
Reduced coding quality issues by re-validating the codes assigned by the CDI team
Improved and maintained the HAC/PSI reporting rates of the hospitals
Productive retrospective physician queries from coding resulted in greater specificity in documentation and MS-DRG
Maintained optimal case mix index (CMI) through the effective collaboration with Access Healthcare's CDI and coding teams
Access Healthcare enables hospitals, health systems, medical groups, medical billing companies, and health plans to grow and thrive. We take a technology-led, people-first approach to transforming your business processes. We infuse scalability and apply our best practices and process automation platform to help you achieve market-leading clinical, administrative, and financial outcomes.