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Clinical Information Transformation

Clinical coding and documentation gap analysis. Medicare and billing – compliance and gaps identification
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Too many health service providers don’t know what they don’t know – to the potential detriment of their patients and organisational performance.

AusHealth’s Clinical Information Transformation Services change that by capturing and analysing the wealth of detailed clinical information held within health services, allowing better understanding of financial opportunities and risk; the source and size of potential compliance issues; and reporting accuracy.

When coupled with our billing, resolutions and revenue recovery solutions, AusHealth’s Clinical Information Transformation Services present health care providers with an opportunity to dramatically enhance operations and bottom-line performance.

The pillars supporting AusHealth’s integrated package of transformational services combine:

  • Industry leading expertise (headed by Dr Paul Tridgell);
  • Benchmarking against Hospital / State / Local Health District results and current acute inpatient coding; and
  • Utilisation of innovative analytical software.

Filling in the gaps

Simply reviewing a hospital’s electronic clinical information in isolation limits your ability to identify gaps.  Significant enhancements can only be made by adopting an integrated package of initiatives to focus endeavours, complete complex analyses, and determine documentation gaps.

The pillars supporting AusHealth’s integrated package of transformational services combine:

  • Industry leading expertise (headed by Dr Paul Tridgell);
  • Benchmarking against Hospital / State / Local Health District results and current acute inpatient coding; and
  • Utilisation of innovative analytical software.

Outcomes from the above may help focus a hospital’s education and training activities; evaluate the structural characteristics of the coding environment; and understand the financial implications of identified gaps.

Benchmarking example:

AusHealth’s innovative analytical software and hospital / State / Local Health District benchmarking may reveal that a hospital is significantly below the expected value of an ICD diagnosis code (DRG, emergency status and age adjusted).  Analysis with linkage to clinical data can identify where the gap is, its value and (if prior to cut off dates for data submission) enable efficient recovery of the activity funding. 

Our Services

Our Clinical Information Transformation Services include:

  • Clinical coding and documentation gap analysis;
  • Impact analysis of coding classification system changes;
  • Analysis of variations in coding processes and outputs;
  • Medicare and billing – compliance and gaps identification;
  • Analysis and monitoring of hospital-acquired complications;
  • AR-DRG Version 11.0 readiness (from December, 2022).
  • Training and education.

Documentation Gap Analysis

The quality of clinical coding of acute inpatients can have a major impact on the Diagnosis Related Group (DRG) allocated to a patient. Too often, complexities including additional medications or diagnostic tests are not documented in a way that can be coded – with a negative impact on funding and the benchmarking of a hospital’s efficiency.

AusHealth allows users to analyse both administrative coded data and clinical data (such as clinical notes, medications, and diagnostic test results) to identify missing diagnosis codes that may change the DRG.

Gap analysis examples:

  • A patient is documented with “Dry mm” and given rapid IV fluids but “dehydration” is not documented. The AusHealth algorithm identifies that the missing dehydration documentation has a DCCL and will change the DRG. 

  • A patient has a low platelet count documented in their notes but not documented as Tests to investigate if the thrombocytopenia was due to HITS meeting 0002 standard.  Thrombocytopenia is not coded, has a DCL and will change the DRG.

  • Clinical documentation and administrative billing data can be used in other ways to recover funds. Staff specialists who have assigned their rights of private practice may not be providing all their billing information for consultation to private inpatients.  Linkages between MBS billing data and clinical notes can identify and recover the otherwise lost revenue.

Analytical auditing service

AusHealth uses innovative analytical software to gather clinical data from across client health services. Sources may include:

  • Notes extracted from the Electronic Medical Record;
  • Pathology/Medical Imaging results;
  • Medication data;
  • Clinical observations. including blood pressure.

The software, which understands the IHPA NWAU model and DCCL values, runs hundreds of algorithms across all episodes of care to identify gaps and missing diagnosis codes – as opposed to the accepted audit practice of searching for key words in a single patient episode.  This comprehensive approach provides operators with:

  • Fulsome data analysis to identify coding gaps;
  • A mechanism to identity possible missing codes for coding/query;
  • Identification and audit of records – frequently including coder/auditor education;
  • An analysis driven approach – identifying knowledge gaps and targeted education opportunities for clinical staff.

Coding classification changes

AusHealth assists analysis of the impact of coding classification system changes on back casting calculations used by the Independent Hospital Pricing Authority (IHPA).

This can be particularly important when analysing the National Weighted Activity Unit (NWAU) output across significant accounting changes.

Coding processes and outputs

Aushealth can assist with the analysis of potential variations in coding processes and outputs in a State or Local Health District (LHD).  This analysis is useful in assessing consistency, under-reported codes, and clinical areas with the greatest opportunity.

A key to this analysis is linking differences in rates of codes to NWAU impact.

Medicare and billing

Under the terms of the National Health Reform Agreement (NHRA) the Commonwealth conducts data linkage to assess compliance with the funding agreement and Medical Benefits Schedule billing.

The AusHealth team has extensive experience in undertaking data linkages to assess compliance with current Activity Based Funding (ABF) under the NHRA. Such analysis may be of particular benefit to a health service seeking to identify risks and gaps or ahead of a scheduled audit.

It is common to identify outpatient Occupational Overuse Syndrome patients (OOS) who  have been reported as private patients yet were seen by a Registrar with no MBS billing.

This can result in health services having significant gaps in inpatient billing of private patients by staff specialists with assigned Rights of Private Practice.  It may be possible to use clinical notes and MBS billing information to identify and recover this lost revenue.

HAC and monitoring

AusHealth can assist with analysis of Hospital Acquired Complications (HAC).

By linking clinical and administrative data, we can also assess the likelihood of a pre-existing condition.

HAC analysis

Clinical information combined with a Clinical Coding and Documentation Gap Analysis can inform the success of quality and safety measures.  For example, for patients with sepsis, we can determine when fluids and antibiotics were given and how early changes in pulse, blood pressure and temperature were noted. 

Further, by granting the HHS Clinical Quality unit access to undertake ad hoc analysis of clinical data, we can assess the size of the issue and where to target changes in practice.

AR-DRG Version 11.0 readiness

The AusHealth team is adept at undertaking readiness audits to help hospitals better anticipate compliance issues arising from proposed and actual classification system changes – for example, from AR-DRG Version 10.0 to AR-DRG Version 11.0 (anticipated for implementation in July 2023).

Being unprepared may create a significant impediment to the efficient operation and financial management of your hospital or Local Health District.

Training and education

AusHealth is registered with the Australian Skills Quality Authority (ASQA) as a Registered Training Organisation to deliver vocational education and training services across all States and Territories of Australia.  AusHealth can provide targeted education in:

  • Documentation
  • Overcoming coding gaps.
  • Data extraction.
  • Clinical coding rules, conventions and standards.
  • Coding classification system changes.
  • AR-DRG Version 10 updates and 11.0.

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