The healthcare environment is frenetic with activity around the use of information systems and the ability to generate “big data” for purposes of discrete analysis of performance and cost. More and more health systems are converting to integrated EHR’s that cover the care continuum from the physician’s office to ambulatory or inpatient care facilities to include a portal for patient access to their own health records. Along the continuum is the need to effectively manage the surgical revenue cycle, analyze evidence-based care outcomes, and to publish the cost of delivering that care in an effort to compare results within or across health systems. At the perioperative level is the need to analyze cost and margin at the service line, surgeon and procedure level while contributing to the financial bottom line. In a June 2016 OR Manager article “Make It Your Business to Grow a Healthy Bottom Line”, Keith Siddel, PhDc, JD, MBA, CHC states, “OR leaders can improve the bottom line by managing the revenue cycle, minimizing denials, improving billing and reimbursement, and understanding business models.”
How does a standardized master surgical procedure file relate to patient-centric care and management of the perioperative revenue cycle? One critical piece of reportable information from the perioperative continuum is the surgical procedure description. Over many years of working with clients, we have seen the Master Surgical Procedure File (MPF) pendulum swing in varying degrees of quality from no standardization to rigid standardization. In the earlier days of perioperative clinical information systems, non-standardized procedure files with a high level of customization in descriptions and approach were the norm. The concept of Healthcare Exceptionalism as found in “Advanced Lean in Healthcare” is defined as “the belief that healthcare provision is so unique, complicated, challenging, and regulated that any lessons to be learned from other industries are largely irrelevant.” This resulted in “homegrown” procedure files because each Operating Room believed they were unique and best suited to develop their own list of surgical procedures. Standardized sources were hard to come by.
More recently, comprehensive and integrated clinical information software and the need for standardization has resulted in software vendors offering “starter content” and professional organizations (i.e. AORN) developing procedure lists that are linked, in part, to industry coded sources.
In Non-Standardized lists, we generally observe:
- Variable “homegrown” sources and descriptions
- 3rd party sources that are not always all-inclusive & subject to source/software release process
- Negative impact on system maintenance leading to missing or duplicative procedures
- Lack of common language to support financial clearance pre-surgery
- Lack of common language between MD office & hospital schedulers
- Lack of common language among clinical caregivers
- Inadequate association of precise resources for each procedure
- Negative impact on reporting and analysis (“apples-to-apples” comparisons difficult)
In today’s world, a better approach is:
- To standardize all procedures & descriptions
- To account for all procedures from the outset in one standardized version (w annual updates)
- To use a Coded list as the initial source (such as CPT); it offers the basis for ensuring a complete list that shares common clinical language and support for accurate financial pre-clearance
- To refine coded sources based on an agreed upon methodology to ensure end-user clinical accuracy
- To ensure that procedure-specific resources of time, staff, room, equipment, supplies and instruments are associated to each procedure for accuracy of scheduling and resource management (i.e. supply chain)
- To allow outcomes and cost reporting that are procedure/surgeon-specific and avoid skewing due to inadequate MPF maintenance or generic grouping of procedures resulting in outliers
- To understand that using a coded source does NOT replace medical record coding or billing; it IS common clinical language that can be adapted for precise and standardized results
To establish parameters around some of the terms we are using, let’s review the following critical definitions:
- Procedure Description – the name of a single discrete surgical procedure with sufficient wording to differentiate one version of a procedure from a similar variation of that same procedure
- Non-Standardized – Common description but without cohesive methodology to support the usual search and sort capabilities of a database table (“what the surgeon’s office is used to calling it”)
- Standardized – Description that contains a clinically accurate and surgically specific approach to word choice, sequence, length and abbreviations
- Coded – Description of a procedure provided directly from an industry source (i.e. CPT procedure description)
- Note: in all cases, you must ensure that the procedure description will work within the architecture and functionality of your information system.
Standardized and coded are not synonymous. Recognizing the difference is the first step in developing a complete and accurate MPF for all end-users. By starting with a coded source (i.e. CPT), all recognized surgical procedures are accounted for. No procedures are missing. Working from a complete list and refining it to support effective scheduling, documentation and reporting is a necessary step. Industry coded lists did not originate to support effective operational management but they should be a component of your MPF to more effectively support a patient-centric culture and improved revenue management.
The use of the MPF is central to the hands-on delivery of patient care. At the core of a patient-centric culture is the commitment to ensuring the dignity and safety of patients. Staff at all levels and of all types must “elevate their game”. It is not OK to be “close” when scheduling a patient for surgery or documenting their care – it must be clinically discrete and accurate. Creating an MPF that meets the need for standardization and accuracy is essential. Simply put, the use of the MPF in a patient-centric OR means:
Pre-Operatively (scheduled procedure)
- Accurate scheduling (right patient, right procedure; right consent) starting with the surgeon’s office where the scheduling transaction begins
- Timely financial pre-clearance/authorization for the correct procedure(s)
- Accurate time allocation for the patient, patient’s family and the OR team
- Appropriate pre-surgical education and readiness of the patient
- Selection of the appropriate facility in which the specific surgical procedure should be performed for best results
- Development of preference cards that are appropriate to the surgical procedure scheduled to ensure optimal resource management (right resources in the room at the right time in preparation for the patient)
Intra & Post-Operatively (actual procedure performed)
- Accurate documentation of the actual procedure performed (especially if it varies from what was scheduled) as a required piece of the patient’s EMR.
- Post-surgical discharge planning & instructions for the patient based on the surgical procedure performed
- Accurate perioperative billing of the patient based on actual case level and specific resources used
The impact of a standardized master surgical procedure file on revenue cycle management isn’t to be overlooked either. Hospitals collect information needed to ensure payment which includes, among many things, the planned surgical procedure in order to obtain authorization. Among the reasons for denial of payment are lack of authorization, level of care, or “not medically necessary.” It is not unusual for a patient to have authorization for one procedure while a different or additional procedure is performed in the OR. There is a small window for getting an updated authorization. While OR’s routinely evaluate the impact on time resources of this change in procedure from scheduled to actual, it is equally important to understand the implications on payment. The level of care required (inpatient vs outpatient) should be established before admission and the case resource level, which is a driver of billing, is a data element typically associated with a specific procedure within the MPF. Denials based on “not medically necessary” are often a case where the procedure was not coded or billed correctly. OR staff & physicians can contribute to the accuracy of coding by using a master surgical procedure file that includes a link to industry codes and supports sufficiently discrete clinical documentation of the procedure performed.
Starting with a standardized or coded source is important, however, bringing cohesion to your surgical MPF requires a dedicated perioperative clinical informaticist with relevant clinical knowledge and critical thinking skills acting as the “communication bridge” between practitioners and IT. These skills permit them to understand & document the rationale for MPF standards to avoid an MPF that “morphs” over time to include duplicative or non-standardized procedures and lacks cohesion or understanding about the source or intent of the file. Ongoing collaboration is the key to successful system maintenance and effective change control.
While development of a standardized list is easier at the time of a new implementation, it is still possible to standardize your MPF in your current production system. It is a worthy exercise to evaluate your existing master surgical procedure file either to improve your existing system & processes or in preparation for conversion to a new EHR.
The big decision is to just “get started.”