Use case - Coding analytics

This topic explores the Clinical Analytics Scorecards Coding Analytics section through an example. For this example, let's assume our hospital suspects a problem with under-coding patients; we want to figure out how to fix this problem so we receive all of our due reimbursement from Medicare.

1. First, we need to open the Coding Analytics section in scorecards. We can use the Coding Analytics Scorecard template (see Scorecard templates), or add the Coding Analytics section to any scorecard (see Customize scorecards).



2. The first report that loads, the Hospital-level report, lists totals for the MS-DRG clusters that received more than the benchmark reimbursement and the clusters that received less.
   1. We can change the report type by clicking the dropdown and selecting from one of the three Top-level reports (Hospital-level report, Physician report, or Specialty report), or the standalone (non-drillable) Overall Diagnosis report.

   

3. For this example, we use the Hospital-Level report to find under-coded patients, so click the MS-DRG Clusters Below Average description.



4. The Cluster report lists MS-DRG (or MS-DRG Clusters) and their related case mix and reimbursement information.
   1. The report defaults to listing individual MS-DRGs. To change the report aggregation (roll up MS-DRGs into MS-DRG Clusters), simply check the box at the top of the section.

   

   2. In this case, we have aggregated by MS-DRG clusters. We can see that the cluster with the highest Total Reimbursement Opportunity is the “Extensive O.R. procedure unrelated to principal diagnosis” cluster.



5. Click a hyperlinked Cluster description to get to the Diagnosis report.This report lists cases in the cluster by secondary diagnosis. This is useful to analysts because it shows which secondary diagnoses physicians may be missing. When we drill into the "Extensive O.R. procedure unrelated to principal diagnosis" Cluster, “Hyperlipidemia, unspecified” is listed at the top with the highest opportunity compared to the benchmark. The difference here is 30.6% (see % Difference in the far right column); the Cases Opportunity column tell us that there were about 42 cases that maybe should have had a secondary diagnosis code for Hyperlipidemia.



6. From the Diagnosis report, we have a couple of options for further analysis.
   1. By clicking one of the hyperlinked Secondary ICD Diagnosis codes, we can view the Overall Diagnosis report; this report can also be accessed in the beginning of the analysis by selecting it in the Report Type dropdown. With this information, we could ask physicians to watch out for certain secondary diagnoses to claim maximum reimbursement.

   

   2. Instead of drilling into a Secondary Diagnosis code, click the Report Type dropdown, and select the Patient Detail report.

   

   3. The Patient Detail report lists the coding opportunity for each patient in the selected MS-DRG cluster. With this information, we can initiate case review for particular encounters for which we possibly did not receive our maximum reimbursement. The Opportunity column lists potentially missed reimbursement if the patient had been coded as CC (or MCC).