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NRMC meetings: revenue, documentation and transfers
This month's meeting of Nevada Regional Medical Center's board and finance committee focused on strengthening services, funding streams and improving documentation for billing purposes.
Outside of the meetings, comments were made about a luncheon meeting between representatives of the hospital and the Vernon County Ambulance District, a meeting reported on by the ambulance director to his board.
At the monthly meetings of the board and finance committee, Kevin Leeper, chief executive officer of NRMC commented on the hospital's present financial position and his expectations over the coming months.
"For some time now, we've been focusing on strengthening our present services and working hard to introduce new ones," said Leper. Not only does this enhance our revenue but people get the services they need, close to home."
The hospital's fiscal year began July 1 and already a number of improvements can be seen.
"When we set our budget, we anticipated some good sized losses in the first half of our year," said Leeper. "But our budget also shows we expect a real turn around in the second half and that we will end up in the black."
Leeper then compared the net loss after the first two months of the fiscal year with what the budget had projected.
"While, to date, we have lost money, to be sure, but notice that we've out performed our budget by over $178,000," said Leeper. "That's huge. This isn't easy and it won't happen overnight but these numbers say we are on the right track and we are even a bit ahead of the game in turning things around."
In his report, the CEO of the hospital laid out the current services being strengthened and cited several new ones.
"The Behavioral Health Unit now has pretty consistent doctor coverage which means it's fairly full and is again providing critical services and a nice revenue stream," said Leeper. "In addition, the 340-B pharmacy program will be up and working in October."
That program allows NRMC to obtain medications at a significantly discounted price. Prescriptions written by the hospitalist or a physician through the hospital and filled at a participating pharmacy permits the hospital to capture those significant savings and thus provides further revenue.
"Dr. Ron Jones, who has been retired for several years, has agreed to resume his pediatric practice through us on, a part time basis," said Leeper. "He begins the first week of October."
Leeper said, "We have accepted a generous proposal from Dr. Lovinger to have Sonja Albright, a family nurse practitioner at our NowCare Clinic to make rounds with him as he visits his nursing home patients. This will permit us to bill for those services through our rural health clinic."
Holly Bush, chief quality control officer, spoke at Monday's Finance Committee meeting about the hospital's efforts at "CDI implementation."
In May 1990, the World Health Organization endorsed the 10th update of the International Classification of Diseases. An American version was implemented in 1999. The Center for Medicare and Medicaid Services, along with private insurance companies have adopted these codes and their classification of diagnoses.
ICD-9 has 14,000 different numeric codes, which are three to five digits in length. ICD-10 has 69,000 codes which are three to seven digits in length and can be letters or numbers.
While ICD-10 was formally launched as the new standard on Oct. 1, 2015, CMS gave a one-year period in which to complete the changeover.
"Oct. 1, is when CMS flexibility goes away and everything we submit has to be coded according to ICD-10," said Bush. "As we've been changing over, we've used this time for CDI."
By partnering with the hospital's consulting service, Quorum Health Resources, Bush and her team have been looking at clinical documentation improvement.
Over the years, it has become increasingly important for diagnoses and procedures to be properly coded. A bit of a game developed as experienced coders learned how to bill for an item using a code, which would receive a higher level of payment.
With nearly five times as many codes, ICD-10 seeks a precise diagnosis. With the introduction of ICD-10, CMS and private insurers also require sufficient notes in a patient's chart to justify a given code.
"Back in June, TrustHCS of Springfield looked at 75 of our records and determined that our three top cases are a diagnosis of COPD, congestive heart failure and pneumonia," said Bush. "They also determined we need to do a better job of providing the notes which justify the billing code."
Ah, but there's the rub. The notes that need to be more detailed are those made the physicians. And since many doctors working with the hospital are not in the hospital's employ, asking them to slow down and spend more time in charting can be a bit of a challenge.
"Instead of putting the docs in a classroom and providing them with training, we get better results by training several case management RNs and have them work with the doctors one-on-one," said Bush. "I can drill down to the specific unit and physician and that way the nurse can focus on the types of things unique to that doctor. We also have those nurses and the coders talking to each other. In this way, we hope to improve chart documentation which will help our coding and billing."
Earlier in September, Leland Splitter, director of Vernon County ambulance district, requested a meeting with representatives of NRMC. The luncheon meeting was requested by VCAD due to concerns related to the volume of patients transferred by ambulance.
In reporting to his board about the meeting, Splitter said the monthly transfer volume on top of local emergency calls was taxing the ambulance service's ability to respond. Until this year, transfers at NRMC had not topped 49 but reached 60 in April and 66 in May but have leveled off at a still rather high 53 in July and again in August of this year. Off duty personnel were called in 40 times in July and 31 times in August.
"There is a lot of money that leaves that hospital," said Splitter.
Following Monday's meeting of NRMC's finance committee, Cory Vokoun, chief of nursing operations commented on the meeting, at which he was a participant.
"We stated we were aware of the number of transfers and that we want to get them down too," said Vokoun. "But I pointed out that in the estimation of the emergency room physician on duty, they were appropriate medically," said Vokoun.
Vokoun noted the types of cases most often resulting in transfer are cardiac, neurologic (including strokes and transient ischemic attacks), complicated surgery cases, and chronic obstructive pulmonary disease.
"We mentioned our ongoing efforts to recruit a cardiologist to be shared with Bates County Memorial Hospital in Butler," said Vokoun. "While that won't replace a heart catheterization lab, it is likely the emergency room doctor would not transfer some cases if, the next day, the patient could see a cardiologist locally."
Vokoun and Splitter each stated they would monitor transfers and while future meetings were likely, no date has been set.