Improving health service planning and reimbursement through quality coding

Abstract

Hospital funding for acute inpatient admissions inAustraliais "Activity Based", such that each hospital unit is reimbursed for each admission based on the patient diagnosis, procedure, complications, co-morbidities and other factors for each patient admitted. This is determined from the clinical documentation recorded by medical staff.  Incomplete or inaccurate clinical documentation has been shown to cost one specialty unit at The Prince Charles Hospital (TPCH), a tertiary hospital inQueensland,Australia, approximately $450,000 of lost reimbursement over a three month period.  To improve clinical documentation, an electronic prompting system was developed and implemented at TPCH.  Medical staff in the cardiology department were required to use this system.  The Diagnosis, Co-morbdities, Procedures and Complications (DCPC) were required to be entered for each patient admission from a drop-down list of clinically appropriate terms. A list containing the DCPC was then printed, signed and placed in the medical record and clinical coders would accurately code from this sheet.  Compared with the same period in the year before, in the two months in which DCPC was implemented in the cardiology department, there was a 6.1% increase in the proportion of patients who were deemed to be the most complex.  Given that there were approximately 900 patients admitted in each of the two months that DCPC was on trial for in Cardiology, this equated to an average increase in revenue per patient by $200 and thus $180,000 in total for the hospital. Thus an electronic prompting system can improve clinical documentation and thus activity based reimbursement a hospital unit receives.