First research what case mix index, (CMI) is and its importance. Second, you nee
ID: 98574 • Letter: F
Question
First research what case mix index, (CMI) is and its importance. Second, you need to explain how the case mix was affected in this scenario(provided below)?
Based on the information provided you should be determining the difference among the incorrect coding by computing the CMI.
Ethical Coding Scenario
Background
Davenport Hospital is a rural, non-profit, acute care facility with approximately 80 beds. The primary payer for the hospital is Medicare, as the majority of it’s patients are elderly. Common diagnoses for inpatient admissions primarily consist of Congestive Heart Failure, Pneumonia and complications of Diabetes due to the aging demographic.
Davenport Hospital has just on-boarded a new Chief Financial Officer after having been without a person in the position for almost one year. One of the first areas of business focused on by the CFO was the days in Accounts Receivable (A/R) for all inpatient admissions as there was a noticeable difference in the Case Mix Index from the year before. Upon initial observation, the CFO noted that there had been a dramatic increase in revenue for a particular DRG, which warranted an outside audit.
Scenario
Dr. Black is a primary care physician with admitting privileges to Davenport Hospital. The patient demographic of Dr. Blacks practice consists primarily of the elderly generation due to the popularity of his bedside manner and his willingness to see patients on the same day they request an appointment due to illness. Dr. Black has a reputation on the inpatient floors of the hospital for directly admitting his patients to the floor from his office on a regular basis and for his extensive diagnosis and treatment regimens.
Elsie Davis is a 64-year-old patient of Dr. Blacks who was directly admitted to Davenport Hospital with an initial diagnosis of difficulty breathing, rule out pneumonia. Dr. Black immediately ordered a chest x-ray on Elsie which showed lung inflammation indicating the presence of pneumonia. In addition to the chest x-ray, Dr. Black also ordered a blood culture on Elsie to aid in determining the type of pneumonia present.
On the second day of Elsie’s admission, after being on IV antibiotics for almost 24 hours and breathing treatments regularly, Elsie was still having difficulty breathing and catching her breath. On the Progress Note for Day 2, Dr. Black had added the diagnosis of Rule out Acute Respiratory Failure, which was a common practice for him.
On day 3 of the admission, the blood culture came back positive for Streptococcus Pneumoniae. Elsie continued to improve with the administration of IV antibiotics and was discharged at the end of Day 3 after being advised to quit smoking cigarettes and to follow up with Dr. Black in one week.
Dr. Black documented in his Discharge Summary that the final diagnosis was Pneumonia due to Streptococcus pneumoniae and Tobacco use.
Coding Synopsis
Below is a screenshot of the coding that was completed by Mary Smith, RHIT, Inpatient Coder for Davenport Hospital using the 3M Encoder.
On day 3 of the admission, the blood culture came back positive for Streptococcus Pneumoniae. Elsie continued to improve with the administration of IV antibiotics and was discharged at the end of Day 3 after being advised to quit smoking cigarettes and to follow up with Dr. Black in one week.
Dr. Black documented in his Discharge Summary that the final diagnosis was Pneumonia due to Streptococcus pneumoniae and Tobacco use.
Coding Synopsis
Below is a screenshot of the coding that was completed by Mary Smith, RHIT, Inpatient Coder for Davenport Hospital using the 3M Encoder.
M Coding and Reimburseme..X ia https://3m.davenport.edulaunchCRS.html FinancingConnecting YoulDv. 3M File View Options Reference Help 1-10| 1-10| 1-10 ICD-10 Summary Add Admit Dx Add Diagnosis Add Procedure Codebook Direct Code Compute DRG Options Analyge Medicare DRG and MDC Information Home, Self Care (1) Female 5 193 SIMPLE PNEUMONIA&PLEURISY; W MCC CMS wt 1.4261 A/LOS 5.8 G/LOS 4.8 Length of stay, discharge to a post-acute care provider, and home health service condition codes can significantiy impact reimbursement for this DRG. 004 DISEASES &DISORDERS; OF THE RESPIRATORY SYSTE Estimated Reimbursement- Medicare Inpatient Total:$0.00 Status: Inlier APR (all versions) DRG and MDC Information 2 139OTHER PNEUMONIA APR wt 0.9394 Low Trim 1 High Trim 16 ALOS 5.34 GLOS 4.51 Status: LOS Inlier RESPIRATORY SYSTEM Major Severity of Illness Major Risk of Mortality 004 Next Patient Admit Diagnosis R064 Hyperventilation Principal Diagnosis J13 Secondary Diagnoses J900 Z720 Pneumonia due to Streptococcus pneumoniae Acute respiratory failure, unspecified whether with hypoxia or hypercapnia Tobacco useExplanation / Answer
Case Mix Index(CMI) is a relative value assigned to a diagnosis related group(DRG) of patients in a medical case environment. The CMI value is used in determining the allocation of resources to care for and / or to treat patients in the group.
Patients are classified into groups having the same condition , based on
1-principal and secondary diagnosis
2- procedures
3-age
4- complexity or comorbidity and
5- needs.
These groups are known as DRGs or Medicare Severity DRGs.
The CMI value of a hospital can be used to adjust the average cost per patient or per day for a given hospital relative to the adjusted average cost for other hospitals by dividing average cost per patient or day by hospitals calculated CMI.
The hospitals calculated CMI is inversely proportional to their average adjusted cost per patient or per day.
For eg. Hosp A has avg cost per patient of 1500$ and a CMI of 0.50 for a given year, their adjusted cost per patient is 1500/0.50= 3000$ and if Hosp B has average cost per patient of 1000$ with CMI of 1.5 their adjusted cost per patient will be 666.7$.
CMI ==sum of MS-DRG weights in a year/ number of patients in that year.
A high CMI means the hospital performs big services and recieves more money per patient. If the hospitals actual CMI is lesser than what finance department predicted, the hospital may experience a loss in revenue.
In the above case..in medicare DRG the patient is admitted with diagnosis of pnuemonia with pleurisy with MCC . DRGs with MCC s reflect highest level of severity. Whereas in APR its diagnosis on admission is pneumonia with no mention of MCC which amounts for decreased DRG.
Also the average length of stay(ALOS) is computed differently in both systems leading to difference in CMIs.
No major surgical procedures like tracheostomy were performed which have high relative weight.
Hence the CMI calculated as per Medicare is more accurate.
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