Briefing: Coding & Workload Accounting Improvement Project (CWAI) Date: 21 March 2007 Time: 1510 - 1600

1. Briefing: Coding & Workload Accounting Improvement Project (CWAI) Date: 21 March 2007 Time: 1510 - 1600

2. Agenda • Purpose • Objectives • Defining the Coding & Workload Accounting Improvement Project (CWAI) • Pre-CWAI Preparation • Findings & Recommendations • Results • Obstetrics/Gynecology Lean Six Sigma CWAI Project

3. Purpose To better understand how workload, coding, auditing, and feedback are intertwined and essential to maximizing a Relative Value Units in a large medical center

4. Objectives • Clinic findings – Determining common threads • Recommendations – Learn how to apply basic workload concepts to your clinic areas • Results – Show how work flow process improvement can increase RVUs and coding accuracy

5. CWAI Background • Why did we implement the CWAI? • From the initial implementation and training of AHLTA at MAMC, it was clear that the system functions were trained, but the work flow processes in each clinic area were not well thought out. This resulted in each clinic re-doing their internal practices with a very wide variation across the facility. This variation showed an adverse effect on visit completion as well as coding accuracy resulting in erroneous RVUs being reported. To bring the clinics into alignment and reduce work process inconsistencies, we began the CWAI project

6. CWAI Background • What is the CWAI? • The Coding and Workload Accounting Improvement project is a clinic-by-clinic, process-oriented training program done by the facility CWAI Super Coder and Coding Coaches in coordination with Resource Management, AHLTA Training Team, and Clinic Chiefs. The facility CWAI coder and team set up a schedule with the Clinic Chief and go into the clinic to observe their work flow processes from start to finish. The team covers work flow, CHCS usage, AHLTA usage and training, UCAPERS and coding. Any opportunities for improvement are corrected or trained immediately or written in the post-visit recommendations. The CWAI maintenance phase is ongoing by the Coding Coach Teams in each clinic

7. CWAI Project • Coding and Workload Accounting Improvement project (CWAI): • Started in Family Practice (FP) area by FP Coder/Coach • Back to basics work flow processes • Shown to improve FP work flow processes and work load data • Decision to expand to all outpatient clinics at MAMC • Continues to be implemented – 3 areas left • Post-CWAI audits, training and continuous feedback done by each clinic(s) Coding Coach(s) • Facility Lean Six Sigma Project for OB/GYN clinics

8. Pre-CWAI Preparation • Team members • CWAI Super Coder/Leads/Clinic Coding Coaches • Clinic Chief, MSAs, Nurse/Techs, Physicians, MEPRS and AHLTA trainers ad hoc • Three separate areas of each clinic were identified • Medical Support Assistants (MSAs) • Nurse/Technicians • Physicians • Developing the schedule • 1-2 weeks (or more) in each clinic area • Identify your clinics needing the most help

9. Implementation Schedule Implementation Schedule

10. Implementation Schedule • Initial meeting with Chief, Head Nurse, Administrative Officer and coding team: • Introductions • Explain the CWAI concept – back to basics • Let them know how this will improve their RVUs • Ask for their full support while the team is in their clinic areas • Make sure they understand that we are there to assist, help, and get them training if needed • Each area’s responsibilities were reviewed: from the front desk through the patient encounter to the end documentation. Process recommendations and changes were implemented and training was provided, if needed, in several different areas

11. CWAI Project Steps RVU Heaven Maintenance Phase – Revisiting all Clinic Areas. Continuous Auditing and Feedback by Coding Coaches Post-CWAI Feedback Training and Recommendations Process Observation Clinic Meeting RVU Hades

12. Findings & Recommendations – Medical Support Assistants • Common Areas for Improvement • End of Day reporting • Need to run this each day after last visit • Basic AHLTA/CHCS functions • Do not use the “Cancelled by Facility” feature • AHLTA appointments – Default Is Established – MSA must change • Ambulatory Data Module (ADM) Compliance Report need to be run • Need fall-back plan when systems are unavailable • DD 2569s – Third Party Forms • Need to complete on all required patients • Process put in place for Third Party personnel to retrieve all forms • Refresher training was given on the areas listed above in each clinic. The importance of correct patient information was also trained to ensure that the MSAs were aware of the critical nature of their jobs. Each patient encounter begins with the MSA

13. Findings & Recommendations – Nurses/Technicians • Common Areas for Improvement • AHLTA/CHCS • Sustainment training done by AHLTA trainer along with team • AHLTA Triage process reviewed and simplified • Coding and documentation • Evaluation and Management (E/M) coding training given on specific nurse/tech codes • Nurse documentation training done to ensure that they are capturing all procedures done during the encounter • Nurse/tech work flow processes streamlined to work more efficiently in high-volume clinics • The CWAI team worked alongside the nursing staff in each clinic to get a better understanding of how the patient was taken care of during their visit. As processes were completed, the team gave on-the-spot feedback and suggestions for improvement. Facility Nursing Staff were very appreciative of the help they had received

14. Findings & Recommendations –Physicians • Common Areas for Improvement • AHLTA/CHCS • Sustainment training given on basic AHLTA documentation features • Establishment of a fall-back plan for system down times • Physicians will receive weekly ADM compliance reports from the MSAs • Documentation work flow processes were reviewed and trained • Timely close-out of AHLTA/ADM encounters • Coding & RVUs • Evaluation and Management training was given on additional E/M codes • Modifier training was done where needed • The importance of RVUs as well as accurate and timely encounter coding and documentation was discussed with each Clinic Chief. Follow-on documentation training will be done at the clinic level by the coding coaches • As with the nursing staff, the CWAI team worked alongside the physicians to assist with their work flow processes and coding of their encounters. Overall, the physicians were pleased that we could spend the time and give them the assistance they needed to ensure their documentation and coding supported the correct assignment of RVUs for their patient complexity

15. CWAI Results • Clinic Work Flow • Streamlined front desk check-in procedures led to faster processing of patients into the clinics resulting in better customer satisfaction • Capture of specific Nurse/Tech procedures has shown to increase clinic RVUs and given the nursing and technical staff an understanding of how critical their input is to the workload system • Coding and Workload Accuracy • Post-CWAI coding audits have proven that refresher training on documentation and coding have increased coding accuracy. As a direct result, more accurate RVUs are being captured in the workload area Next slides demonstrate our Lean Six Sigma Project for sample clinic results from OB/GYN

16. Project description Decrease the percentage of appointment-inferred SADRs from 21% to 10% over the total number of encounters over the next 2.5 months Increase baseline clinic Current Procedural Terminology (CPT) coding accuracy by 10% or greater over the next 2.5 months in the Obstetrics and Gynecology Clinics (MEPRS: BCB, BCC, BCD) Review front desk functions, provider functions, clinic coding coaches, appointment booking, outpatient records (electronic & paper), AHLTA scanning, clinic chart preparation, end-of-day processing, GME services and medical student documentation guidelines CWAI OB/GYN Lean Six Sigma Project

17. Value Stream Map

18. C-E Diagram

19. CWAI OB-GYN – Primary Metric – Post

20. Cost Savings Project Benefit

21. Major changes the project team implemented Incorporated documentation/coding compliance Set up initial/retraining for staff Assisted with identifying roles (nurses, tech, clerks) Assisted with establishing business practices Assisted in transition to paperless system Coordinated with IMD, Credentials, Clinical Ops, Clinic PAS supervisors for provider’s validation in CHCS Closed out noncompliant ADMs with clinic staff Key learning of the project Accurate and timely data completion of all workload related areas Clinic awareness of RVUs and their critical role in workload What impact does this improvement have on IMA? Decreased inferred rate represents $170,788 in additional PBAM revenue for first four months post project CWAI OB/GYN – Results

22. Lean Six Sigma CWAI OB/GYN Results Pre-CWAI incomplete encounters had an estimated lost revenue worth of $580K

23. Summary • Discussed clinic findings – Determined common threads among all facility clinics • Learned how to apply basic workload concepts to clinic areas • Shown results on how work flow process improvement can increase RVUs and coding accuracy