An Epic Journey –Real Charge on Documentation and

Other Topics

Joyce L. Lang, CPA, CIA

2011 AHIA Annual Conference

www.ahia.org

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Background

Joyce L. Lang – Director of internal audit at Legacy Health for 10 years, through June 2011

Legacy Health – 6 hospitals, 50+ clinics in Portland, Oregon metropolitan area

Development of 18 Epic modules began in 2008

First clinics live in August and first hospital in November 2010; completed September 2011

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Agenda

Charge on Documentation (COD)

– What we did and how we did it

– Examples

– Obstacles and lessons learned

– Questions

Epic Roundtable

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Charge on Documentation

What does it mean?

The Journey starts

– Demonstration by Epic Analysts

– Charge Capture Navigator

– Oops!

– Add charging rows?

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Executive Support

Presentation to executives, including CAOs

Memo from CEO and CFO to Legacy

leadership and Epic project team

– Purpose – clarify and advance COD philosophy

– Focused on Quality Documentation, not

charging

– Multidisciplinary teams to link documentation and

charges

Epic Charge Steering Committee

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Epic COD Defined

Epic has the tools for embedding charging in

the documentation of patient care so that

charging is, in most cases, invisible and

effortless to the healthcare team. Goal is

that, for most charges, entry of the charge is

not a separate action from the

documentation of care.

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Epic COD Steering Committee

VP Revenue Cycle and Director Internal

Audit were co-chairs

Orientations (with Epic) for Epic project team

and operations to gain buy-in

– Philosophy

– Charge methods

– Responsibilities and process

Monitor progress

Approve use of non-COD method

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Epic’s Inpatient COD Options

Interfaced Order Resulting

MAR Documentation

Enter/Edit Resulting

Task-based Order Completion

Procedure Navigator

Flow sheet (with approval)

Charge Navigator & Charge Router (exceptions)

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Workflow Change

Weekly meetings

System wide clinical users, Epic Analysts

Every charge from department sheets

Details, details, details

– Bladder scans

– Hearing tests

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Build Results

Interfaced Order Resulting – Labs 100%

orderable in Epic, Cerner interfaces the

charges

MAR Documentation – 100% of medication

charges

Enter/Edit Resulting – Used for point of care

(non-interfaced) tests

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Build Results

Task-based Order Completion =

Orderable/Performable

– Radiology – 95%

– Respiratory Therapy – 75%

Procedure Navigator – Note writer used in the

Emergency Dept and for Inpatient physicians

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Build Results

Flow sheet

– Nursing – 90%

– Inpatient Rehab – 90%, Outpatient Rehab – 10%

– Respiratory Therapy – 25%

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Flow sheets

Wording of flow sheet rows - documentation

is of service performed

Start and Stop Times

– Aerosol tent hood mask, high flow nasal

cannuala, vents

– Women’s – anti-partum, labor and post-partum

– Newborn phototherapy

Supplies charges attached to procedure

documentation

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Flow sheet – Specific Charge Rows

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Flow sheet – Drop Down

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Charge Router Rules

Vaccination administration (clinics)

Medication administration (clinics)

Employed vs non-employed providers

Tissue calculation

Direct to observation

Custom packs

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Emergency Department

95% automated

Facility Leveling– Documentation of care activities

– Automated calculation

– Review and acceptance

Note Writer– 66% charged and coded from documentation

– Coders still review before posting

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Facility Leveling Tool

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Note writer

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What didn’t work

Infusions and hydrations

Medication administration – inpatient

Observation hours

Oxygen - start and stop times. RT reviews

time on oxygen and enters quantity every 12

hours

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Obstacles

Ownership – Is it a clinical or revenue cycle

process?

Testing – How does it change with COD?

Training – Should it change for COD?

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COD Testing

Unit – charge set-up exists

System – did documentation throw a charge,

the right charge, and to the right place

Integrated – limited testing

Day in Life – revenue and clinical teamed,

copied medical record and entered care

provided to get same results

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COD Training

Epic training covered how to document, little

on where to find documentation/charging

points

Disagreement on adequacy of training

Requested charge map – resistance

Map for one department – path

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Lessons Learned

First hospital struggled with charging at go-

live

Next hospitals – 3-tier training at dept level

– Basic COD concept training

– Cross-walk review (where/how each charge

should drop in Epic)

– Pre-go live check for access, security, questions

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Lessons Learned

Created new charge monitoring procedures

– Daily revenue scorecard and variance reporting

– Weekly call between managers and Revenue

Integrity team to discuss cause of variances

Focus groups

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Charge Review – General Tools

Census / schedule

Revenue and Usage Report

Custom report for Ambulatory review

– Open encounters

– Number of patients and dollars

– Work queue

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ED Charge Review

Nurse reviews LOS calculation and accepts

Revenue & Usage - Scan report for unusual & missing charges, compare # of patients to ED Census Yesterday

Critical Care – ID admit, death, transfer dispositions, read physician notes

Monitor – Daily Revenue Scorecard, Facility Leveling Bell Curve

Medication usage – Pyxis vends w/o MAR charges

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OR Charge Review

Case logs to schedule

Business Coordinator validates case level,

duration and supplies, including checking

dictation and patient consent

Implant usage reconciliation to stickers,

Central Sterile’s set inventory, dictation,

vendor records

Supply and implant pricing automated (mark-

up of Lawson cost data)

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Cath Lab Charge Review

Compare MacLab Event Log to Epic

Cardiant case log

Usage reconciliation

Physical inventory reconciliation – Epic

decrements Lawson perpetual inventory,

compare physical and record counts

Monitor daily Revenue Scorecard

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Charge on Documentation

Questions?

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Other Topics

Roundtable Discussion

Save the Date: August 26-29,

2012

31st Annual

Conference in

Philadelphia

Pennsylvania