The APG Corner
Hospital still has APG headaches after 4 years
Adjustments aren’t over yet
[Editor’s note: Broadlawns Medical Center (BMC) in Des Moines, IA, has had four years to adjust to Iowa’s mandatory use of ambulatory patient groups (APGs) for Medicaid patients. Still, problems occur, and hospital staff may have even more headaches once Medicare implements its new payment classifications for hospital-based outpatient facilities, says Kelly Huntsman, RRA, director of medical information management. The nonprofit, county facility provides services that exceed 200,000 ambulatory visits each year, and approximately 25,000 of those visits are paid under Iowa’s APG system. Services include emergency, ambulatory surgeries, primary care, psychiatric and substance abuse, and many other medical specialties.
Huntsman discusses how the hospital has coped so far with APGs and what still needs to be done.]
ORM: What kind of changes did you have to make after your hospital implemented APGs for Medicaid patients?
Huntsman: We had to make some significant changes to our system, primarily with the way we collect data and generate bills.
One of the significant differences with the APG system is that it is based on CPT/HCPCS procedure coding as compared with the DRG system which is based on diagnosis codes. The difficulty with this is that your information [i.e. codes and charges] is coming from numerous points throughout the medical center rather than one centralized coding area. For example, the procedures that are performed in the ambulatory settings are charged and coded utilizing a charge ticket and the Chargemaster system. The individuals handling this information vary by clinic but could include the physician, nurse, medical assistant, unit clerk, etc.
This poses several issues. One, training is much more difficult when you’re dealing with a large number of individuals who have varied knowledge bases and little coding experience. It’s much easier to make changes in a process that impacts five coders instead of 100 employees. Secondly, with data coming from various points throughout the system, data validity and integrity was an issue. We had to take a close look at all of the data entry points to make sure all services were being captured in the appropriate manner and that information was flowing to the appropriate places.
The whole issue of data collection at BMC was complicated by the sheer volume of accounts. Before APGs, we had a bill cycle where we’d send out a bill once a month that contained all of the charges for the patient for that month. Because the APG system required a separate bill for each encounter, we had to set up accounts for each patient visit/encounter.
We initiated this change for all patients regardless of payer because so many of our patients are indigent and are in and out of assistance programs on a frequent basis. That means when you have 200,000 outpatient visits each year, you have 200,000 accounts generated. To complicate things a little further, Iowa Medicaid required that we bill encounters that occurred within 72 hours on one bill if they were for like diagnosis.
All of these issues required that data collection processes were well-defined and understood by staff and that the hospital information systems were structured to accommodate these changes.
ORM: How well has the APG system worked?
Huntsman: We’re doing better. We made initial changes to our data collection processes, but we find that this is an ongoing process as services and staff change. Monitoring the process is very important, and that is something we continue to do.
ORM: How did these changes impact your department?
Huntsman: We ended up adding one coder to our staff. The individual assisted the ambulatory areas with the coding process and also did a lot of monitoring and clean-up work. We tried after two years to do without the additional staff person; however, we found we couldn’t do it.
ORM: Will this process of switching to APGs help you at all when you have to make changes to accommodate the new Medicare system of ambulatory payment classifications [APCs]?
Huntsman: Yes. The changes we made to our data collection processes and our billing systems will all be relevant, and the basic concept of grouping outpatient services for purposes of reimbursement will be very similar. The difficulty will come in the different requirements and interpretations that Medicare will implement. For example, Medicaid has a 72-hour window — meaning that all encounters for like conditions that occur within 72 hours must be grouped together on one bill. The indication that we’ve gotten from Medicare is that their window will be 24 hours. Thus, you’ll be working with two different sets of rules.
What it will come down to is collecting good information up front from the patient and making sure that your processes and information systems can address the different rules that may be required for Medicare.
Source
For more information about Iowa’s APGs, contact:
• Kelly Huntsman, RRA, Director of Medical Information, Management, Broadlawns Medical Center, 1801 Hickman Road, Des Moines, IA 50314. Telephone: (515) 282-5665. Fax: (515) 282-2231. E-mail: [email protected]. World Wide Web: http://www.broadlawns.org.
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