1. Lessons Learned Following Pathways Claims Validation
Robin Acino MPH, Julie Mason RVT, Todd Russell MD, Fedor Lurie MD PhD, Babatunde Oriowo, MD
Jobst Vascular Institute
ProMedica Health System
Toledo, Ohio
Good Morning, I’m Robin Acino from Jobst Vascular Institute, in Toledo, Ohio. I will present today on our QI project Lessons Learned following the Pathways Claims Validation.

2. 2017 Procedure Claims Validation
Problem
2017 Procedure Claims Validation
12.5% of VQI cases submitted improperly coded
CEA’s coded as percutaneous intervention
CEA’s coding referencing only common carotid artery
Peripheral Vascular Interventions coded as coronary arteries
Bypasses coded with wrong arteries involved
Open AAA’s billed at EVAR’s
Standard EVAR’s billed as fenestrated graft
As part of the claims validation process in 2018, a review of 2017 mismatched cases were audited which identified some obvious opportunities to improve billing/coding and documentation. 12.5% of our VQI cases had coding errors, often found among Carotid Endarterectomy & AAA procedures. Most common issues were percutaneous billing for open procedures, inaccurate arteries coded in CEA’s, peripheral interventions and bypasses, and numerous problems with AAA repairs such as open procedures billed as EVARs and standard endografts billed as fenestrated or branched grafts.

3. Review the results of the claims audit to identify:
Goal
Review the results of the claims audit to identify:
Accuracy of coding
Impact to the organization
Opportunities for improvement
Action plan to address deficiencies
Continued QI project plan
It was the goal of this project to review our data and determine the accuracy of billing & coding including the impact on financials. We partnered with the Health Information Management (HIM) and hospital billing and coding team to address the issues and identify opportunities for improvement. It was a collaborative effort to address deficiencies and implement proactive monitoring to have timely identification of errors and minimize losses going forward.

4. 2017 cases reviewed Results 6 DRG cases were incorrect
Net Impact: $23,622
Results of our internal audit caused the HIM department to review and re-code approximately 60 cases, most of which did not require a change of the diagnosis related group (DRG). 6 cases did change the DRG: two had coding changes resulting in a loss of over $17,000 dollars, two were billed at a gain of just over $12,000 dollars. Two cases were deemed too old to rebill, but would have resulted in an additional $29,152 in charges. The net gain of these 6 cases was over $23,600. Which may not seem like a lot of money but is more than we pay to participate in VQI.

5. Improvement Strategies
Collaborative approach to education
Health Information Management (HIM) team & billing/code staff assigned education from American Health Information Management Association (AHIMA)
HIM team reviewed/updated “auto-suggest” indicators for key procedures
100% SMART review for all CEA and AAA repairs for 2019
The true benefit of this project was the collaboration that resulted between the billing and coding team and Jobst Vascular. Our initial meeting with their team was met with a tremendous amount of anxiety and angst on their part – they were very concerned that we were upset and angry with the outcomes, whereas we were their welcoming their input on how we could all do better. The HIM team assigned a number of education modules to their staff, reviewed the guide tools in EPIC that auto-suggested the coding, and implemented 100% SMART review by the system as well as their leadership for all CEA and AAA cases for this current year.

6. Improvement Strategies
Jobst Vascular Institute staff provided onsite lecture featuring anatomy and Q&A to 40 HIM staff
The direct education of the staff by Dr. Nizar Hariri one of our Vascular Surgery Fellows & attending Dr. Sophia Afridi was probably the most impactful strategy that we offered. Dr. Hariri gave a basic, yet thorough anatomy lesson, complete with drawings, displaying endografts and reviewing key terms regarding vascular procedures. The coding staff admitted vascular is by far the most difficult specialty they are charged with coding. Following the session, I received an from over half of the attending's thanking our team for their efforts and providing suggestions for future topics to cover. It was an obvious sign that more education is needed and welcomed.

7. Improvement Strategies
Physician Documentation
Feedback on errors
Challenges with learners
Goal to optimize EPIC
Physician documentation was another area with opportunities for improvement. Errors were unidentified amongst nearly all of our physicians so we took the opportunity to emphasize the need for key terms required or clarifying documentation in OR notes to help facilitate accurate coding. As a teaching service, the frequent rotation of residents identified that we need to include details in our orientation and service line handbook to ensure consistency and last, is the opportunity to optimize EPIC. There are multiple ways that we can use technology to help us get it right, with the use of smart sets, dot phrases and note templates.. yet our system has not yet embraced the importance of maximizing these tools.

8. Challenges & Lessons Learned
Difficult specialty
Time and resources
System
The challenges that we face on the project is helping the coders understand the complexity of vascular and finding time among everyone’s schedules to keep educating the staff. We have long been requesting help from our IT/HIM departments for assistance in implementing templates for documentation but often were put off due to other priorities, future upgrades, etc. This project has been helpful in gaining some attention and momentum, even with the relatively small financial impact that was identified.

9. Success Factors Success Factors Collaboration among departments
Data supported need for education & EPIC development
Ongoing monitoring
“His diagrams and information was shared in a way that it was very clear he was trying to make sure we not only understood but completely grasped the details of what he was explaining so when we are coding the procedures we comprehend the whole picture and can then accurately code them for billing purposes”
“I have to say, this is one of the best education presentations I have received in all my years with ProMedica”
Our greatest success is the relationship that resulted between the two areas, as it was unique but welcomed by both parties. Additionally, it helped to identify the importance of ongoing education and need to utilize tools that are available to minimize errors and maximize reimbursement. We are currently reviewing 2018 procedures in a similar fashion and have additional education efforts for the coding staff planned.
“I was so very impressed with the presentation this morning. It was packed full of information and great drawings. Dr. Hariri and Dr. Afridi were both very clear and informative in the knowledge they shared with us.”

10. Questions?