Innovation case study submitted by NMC during 3rd Continual Improvement & Innovation Symposium organized by Dubai Quality Group's Continual Improvement Subgroup to celebrate World Quality Day 2011.

1. Innovation Storyboard
Abu Dhabi
EVALUATION & MANAGEMENT CODING
DOCUMENTATION BY PHYSICIANS
– A PROCESS AND ROLE INNOVATION
July ‐ September 2010
NMCSH ‐ AUH
1

2. 1. About the Organization
Abu Dhabi
• NMC Specialty Hospital, Abu Dhabi is a multi‐specialty hospital
providing quality and trusted secondary and tertiary healthcare
services to the people of Abu Dhabi.
• Established in 1975.
• ISO 9001: 2008 certified, ISO since 2000
• Joint Commission International (JCI) accredited – May 2010
• Average Out patients (OP) visits – 1400
• Number of Patient Rooms / beds ‐ 100
• Number of ICU Beds ‐ 7
• Number of Nursery Beds ‐ 4
• Number of Operation Theaters ‐ 7
• Number of Doctors ‐ 150
• Number of Nurses and Paramedics ‐ 370
2

3. 1. About the Organization (contd.)
3

4. 2. The Idea
• How was the opportunity for innovation identified? What was
the business problem/opportunity?
The Health Authority – Abu Dhabi (HAAD) had made it a requirement
that all healthcare facilities adopt E&M (Evaluation & Management)
codes and charges for Out Patient physician consultations. The
healthcare facilities of Abu Dhabi should be certified by 01st
September 2010 through a 3rd party before they are allowed to do so.
The charges as per the E&M codes, is considerably higher than
current charges.
After this date those hospitals who were not certified would only be
allowed to charge a flat rate of AED 68, which is the lowest among the
proposed E&M rate for all OP visits (irrespective of the insurance
plan). This would be highly unviable option.
4

5. 2. The Idea (contd.)
• How was the opportunity for innovation identified? What was
the business problem/opportunity? (contd.)
Projected increase of OP visits by 10‐15% in the year 2011 i.e. 1600
OP visits
Projected increase of patients covered by insurance is expected to
increase from 90% to 92%
We have adopted E&M coding for OP visits as a part of the mission
of the hospital i.e. aligning with the healthcare vision of Abu Dhabi.
5

6. 2. The Idea (contd.)
What preliminary research was carried
out (list sources)?
• 1995 Documentation Guidelines For
Evaluation & Management Services
• 1997 Documentation Guidelines For
Evaluation & Management Services
• Evaluation & Management Services
guide
• Joint Commission International
Accreditation Standards for Hospitals,
3rd Edition,
• HAAD Hospital Standards, 2008
• Daman Abu Dhabi Plan E & M Codes
And Prices (Plan with the lowest rates) 6

7. 2. The Idea (contd.)
DAMAN ABU DHABI PLAN E & M CODES AND PRICES
S. No New Patient Charges Established Patient Charges
Code (in AED) Code (in AED)
1 99201 126 99211 68
2 99202 219 99212 130
3 99203 321 99213 211
4 99204 492 99214 318
5 99205 620 99215 431
The Daman Abu Dhabi Plan had prices of AED 65, AED 85, AED 122 for Out Patient
consultation with General Practitioner, Specialist and Consultants during the
study period. This was the lowest among the insurance charges.
7

8. 2. The Idea (contd.)
• How was the project prioritized?
– The project was given very high priority since it affected the
revenue cycle and had a short period for implementation.
– Also, it was required to comply with HAAD regulations.
8

9. 2. The Idea (contd.)
Tools/Techniques to generate the idea
• Brainstorming
• Revenue projections
• Project Study
Gap Analysis
Talent assessment
– Two physicians were deputed , they underwent online training and
also attended workshops regarding coding conducted by the
HAAD.
Competency Assessment
– This was done to assess the understanding of E & M coding
guidelines by the physicians
9

10. 2. The Idea (contd.)
Advantages / Disadvantages of various alternatives
Various alternatives were studied and discussed before
implementation of the project.
ALTERNATIVE – I (not undergoing E&M coding certification)
• All types of Outpatient visits would get a flat charge of AED 68
(lowest of Daman, Abu Dhabi plan E&M Charges) irrespective of the
insurance company or complexity and management the illness
• There would be a 30.79% loss of revenue i.e. AED 16,253,085
• There would also be an opportunity loss of 50.41% i.e. AED
26,608,865
• Therefore the net loss would be 81.20% i.e. AED 42,861,950
10

11. 2. The Idea (contd.)
Advantages / Disadvantages of various alternatives
ALTERNATIVE II ‐ E & M Coding by Certified Coders
• Additional revenue generated would be AED 26,608,865 (50.41% )
• Very high costs i.e. additional annual cost for 40 coders = AED
2,880,000
• 5.46% of the projected gross additional revenue will be spent on
employing coders.
• Net increase in revenue = AED 23,728,865 (44.95%)
• Lack of certified coders in the local market
• Sudden demand for coders in Abu Dhabi alone
• Documentation has to be done irrespective of whoever is doing the
coding
11

12. 2. The Idea (contd.)
ALTERNATIVE III ‐ Outsourcing E & M Coding
• High costs, on par with ALTERNATIVE II
• Issues with confidentiality of patient information.
• Delay in processing claims.
12

13. 2. The Idea (contd.)
Advantages / Disadvantages of various alternatives
ALTERNATIVE IV ‐ E & M Coding by Physicians
Advantages:
• Real‐time coding
• Increased sense of ownership for documentation because “Not
documented, not done; not done means will not be paid for”
• Low cost, mainly training cost
• Less number of coders i.e. annual cost of 4 coders = AED 288,000
• Additional revenue generated would be AED 26,608,865 (50.41% )
• AED 288,000 (0.55%) of the projected gross additional revenue of will
be spent on employing coders and AED 30,000 (0.06% )would be
spent on training
• Net increase in revenue by AED 26,290,865 (49.80%) i.e. 4.85% more
than when coding by coders 13

14. 2. The Idea (contd.)
Disadvantages:
• Modification of documentation methodology; this is required even
if the coding is done by the coders.
Based on the study it was decided that Alternative IV ‐ E & M
Coding by Physicians would be a sustainable model.
14

15. 3. People Involvement (contd.)
• How was the team formed (cross‐functionality) ?
Interdisciplinary team was formed with representation from:
– Physicians
– Medical records including Medical coders
– Insurance
– Nurses
– Quality department
– Administration
– Human resources
Training team consisted of members from Physicians, medical
records & medical coding specialists
15

16. 3. People Involvement (contd.)
• How was the stakeholder buy‐in acquired?
– Having trainers from physicians helped us in understanding their
perception and to reach out to the physicians.
– The following advantages were discussed:
• Reduction of documentation time
• More time for clinical examination & patient interaction
• Increase in Department revenue
16

17. 3. People Involvement (contd.)
• How were the resources / budget determined and obtained
for the project?
– Training cost – 20,000 AED
– External Auditing cost – 10,000 AED
TOTAL COST = 30,000 AED
– Annual cost of 4 coders = 288,000 AED
17

18. 4. Process (contd.)
• Explain the process of developing the concept into a detailed
plan of a practical solution?
– Study of JCI & HAAD standards, E&M documentation guidelines
– Training on the E & M coding documentation guidelines
– Development of Department specific Assessment forms in
collaboration with physicians, medical coders & quality
department
– Training on the new assessment forms
– Pilot testing of the forms i.e. 2 forms per physician per
department
– Auditing of forms and checking the conformance to
documentation guidelines
18

19. 4. Process (contd.)
• Explain the process of developing the concept into a detailed
plan of a practical solution? (continued…)
– Modifying the forms based on the feedback
– Retraining based on the deficiencies that are found during audit
of the completed forms
– Deployment of the modified forms for all patient visits
– Auditing of forms and checking the conformance to
documentation guidelines
– External audit by 3rd party
– Certification for E&M coding
19

20. 4. Process (contd.)
Gantt Chart
20

21. 4. Process (contd.)
• How was the feasibility of the solution evaluated? What
tools/techniques were used for analyzing feasibility?
1. Competency of the doctors to code using Competency tests.
2. Internal inventory of talent to design an acceptable, compliant
easy‐to‐use form‐ using Talent inventory.
3. Revenue projection‐ Net revenue gain of AED 26,290,865
(49.80%)
4. Opportunity loss of AED 42,861,950 (81.20%)
21

22. 4. Process (contd.)
• Was any Risk Assessment carried out (risks involved in the
proposed solution itself)?
– Inaccurate coding – risk
– Irrecoverable receivables due to insurance rejection.
– Comparison of Financial risk of proceeding with certification and
not proceeding with the same.
22

23. 4. Process (contd.)
• How was the Idea (solution) pilot tested for implementation?
• The modified specialty specific forms that were developed were
pilot tested i.e. 2 forms per physician per department
• These forms were audited by the coders and the quality
department on a daily basis
• Feedback about the forms received from the physicians i.e.
spacing, addition, deletion etc.
• Feedback provided to the doctors about the completeness and
accuracy of the documentation
23

24. 4. Process (contd.)
ROLE INNOVATION
• Doctors were trained to code the consultation as a part of their
documentation. Doctors therefore took on the role of the coder
thus reducing the need for separate coders for E&M coding.
• Thus, a costly layer of coders in the process of finalizing the claim
was removed. A significantly lesser number of coders (thin layer)
are involved in audits and personal feedback to ensure a sustained
level of high accuracy of coding.
24

25. 4. Process (contd.)
FORM INNOVATION
• Incorporation of E&M coding documentation requirements.
• Improved data capturing by tick marks instead of free hand writing.
25

26. 4. Process (contd.)
Old version of forms
26

27. 4. Process
New version of forms
27

28. 4. Process (contd.)
MISTAKE PROOFING
• Comprehensive checklist methodology which gives the doctor a reminder
to ask relevant questions.
• Incorporates the coding calculation as a part of the flow of the document
capturing, enabling the doctor to score along the way.
What were the results for the pilot trials?
– Results showed a coding accuracy of 80.6% during pilot trials.
28

29. 4. Process (contd.)
• How was the full scale implementation planned?
– The assessment forms were further modified based on the
feedback
– Retraining was done focusing on deficiencies found during the
audit of the completed forms
– Deployment of the modified forms for all patient visits from 15th
July, 2011
– A continuous audit of forms was performed to ensure the
highest accuracy
– Target was to obtain a E &M coding accuracy of 90% and overall
coding accuracy of 95% by 30 August 2010
29

30. 4. Process (contd.)
• How were the risks at the various stages of implementation
identified and mitigation planned?
– The inaccuracies identified were under‐coding, over‐coding and
incomplete documentation
– One to one feedback was provided to the physicians
– Assessment forms were further modified with inputs from the
physicians to make it user‐friendly
– Coding audit process was started to ensure that the process of
coding was correctly complied with and led to highest accuracy
of coding (please refer next slide).
30

31. 4. Process (contd.)
• How was the implementation monitored and controlled?
31

32. 4. Process (contd.)
• How were the various stakeholders informed and
their support obtained?
– Training
– Meetings
– Administrative Rounds
– One‐to‐one communication
– Intranet communications
32

33. 5. Results
External audit by 3rd party was completed by 01st Sep 2010
Planned Actual
• E & M coding Accuracy – 90% • E & M coding Accuracy – 91%
• Overall coding accuracy – 95% • Overall coding accuracy – 97%
33

34. 5. Results (contd.)
What were the actual benefits realized from the
implementation?
– First private sector hospital in Abu Dhabi to complete coding audit
successfully.
– Improvement of overall medical documentation
– Lesser time spent for medical documentation.
– Annualized increase in net revenue of AED 26,290,865 (49.8%)
– A saving of salary expenses for additional coders of AED 2592000
– An avoidance of an opportunity loss of AED 42,861,950 (81.2%)
34

35. 5. Results (contd.)
What were the actual benefits realized from the
implementation? (contd.)
The benefits support the strategic objectives and mission of the
hospital:
1. Increasing net revenue.
2. Decreasing expenses.
3. Increased patient satisfaction.
4. Compliance with regulatory requirement.
35

36. 5. Results (contd.)
• List other intangible benefits
– Helped in standardization of documentation
– Enabler for better documentation
– Address the issue of illegibility of doctor’s notes
– Helped in preparation of templates for Electronic medical record
– Replication of the same documentation methodology across 3
hospitals under NMC healthcare
– Increased efficiency of physicians
– More time for physician‐patient interaction
36

37. 5. Results (contd.)
• How was feedback obtained from various stakeholders? How
were they impacted? What was their perception?
1. Patient satisfaction survey.
2. Feedback from doctors
3. Coding audits by coders
4. Feedback from insurance department.
The overall impact was a positive one. The doctors found the new
assessment form quite time saving and easier to use.
37

38. 6. Learning
• What Went Well and What Went Wrong?
– What Went Wrong – the date of start of using the
E&M coding based rates was postponed.
– What went well – simplification of gathering
patient information.
38

39. 6. Learning (contd.)
• Single Point Lesson Learnt?
• Innovation of the current medical documentation to
incorporate E&M coding requirements led to regulatory
compliance, better documentation and greatly increased
revenues.
REPLICATION
• Replication of the same documentation methodology
was implemented across 3 hospitals under NMC
healthcare
39

40. 6. Learning (contd.)
What would you do differently the next time you do a
similar project?
• We would try to implement it in an e‐format right from the
beginning.
40

41. 7. Way Forward
• How were the team members recognized?
– Coding accuracy was included as one of the
criteria for judging the best department.
– Certificates were distributed to the trainers and
best departments.
41

42. 7. Way Forward (contd.)
• Future development of the idea or using the same
idea in different applications
– Nursing e‐documentation.
– Quality e‐documentation.
– Infection control e‐documentation.
– Operation theatre e‐documentation.
– Day care e‐documentation.
– Observation e‐documentation.
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43. Q & A
43

44. Thank You
44