APPENDIX H

 
PEARLS PROGRAM
 Decrease Denied Days
Through Improved Physician Documentation


PEARLS is a physician newsletter published monthly with a focus on top denial generating DRG's. Each month's one-page publication features a different DRG and includes the following information:
  • Summary of hospital's current performance related to number of denied cases and days; our LOS compared to the state's, and the "goal" LOS per payor guidelines
  • "Points To Remember" - based on good physician documentation that justifies patients' LOS (based on actual chart reviews)
  • List of commonly missed co-morbidities
  • Payor guidelines

These newsletters are presented by our PEARLS physician team member to the various medical staff department meetings monthly. They are also available in notebooks throughout the hospital and are sent to their office practices for use in their office.

In additions, PEARLS "re-measures" are published monthly. These graphs of improvement demonstrate the decreased denial days over a year period. Along with the graphs, we add reminder pointers and any new payor guidelines that are appropriate for that DRG. Doctors love to see the improvement. Physicians have found the PEARLS newsletters and notebooks so helpful, they are requesting they be available "on-line" for quick reference. In addition, members of our Medical Staff are suggesting other ideas for publication as well as certain DRG's they would like to have highlighted to improve clinical performance.

The PEARLS Notebook contains an implementation plan and a series of physician newsletters covering the following DRG's:
  • 14—CVA
  • 358, 359—Uterine Adnexal Procedures
  • 79, 89—Pneumonia
  • 127—Heart Failure
  • 174—G I Bleed
  • 143—Chest Pain
  • 88—COPD
  • 296, 297, 298, 182, 183, 184—Dehydration and Gastroenteritis
  • 148, 149—Bowel Surgery
  • 416—Septicemia
  • 124, 125—Unstable Angina
  • 107—CABG with Cath
  • 430—Psychoses
  • 20—Nervous System Infection (Bacterial Meningitis; Guillain-Barré Syndrome)
  • 128, 130, 131—DVT
  • 141—Syncope
Non DRG PEARLS:
  • Compliance
  • Blood Loss Anemia
  • Breast Cancer Screening and Diagnosis
As a result of our PEARLS program, in combination with our Patient Care Management Department, we have realized a decrease of denied dollars from $1,609,300 (1998) to $537,250 (through March 2000).

Representatives from the PEARLS team are available for site visits if you are interested. (See Price List included.) During our visit, we can provide you with strategies about how to operationalize the program at our institution. We would look forward to meeting with you.
PRICE LISTING
CD ROM      ..........................................................

$1500
CD ROM with

 
    PowerPoint presentation     ...........................

$2500

Site visit:

 
   includes CD ROM and three-hour presentation …

$5000 + our expenses
        Dr. Chris Snyder  
        Dr. Tom Lawrence  
nbsp;       Donna Thompson  

For more information or to purchase the PEARLS program, contact Donna Thompson, RN, Director of Clinical Quality Improvement at:
   Phone:   410-543-7740
   Fax:      410-543-7010
   E-mail:   donna.thompson@peninsula.org
   Peninsula Regional Medical Center
   100 East Carroll Street
   Salisbury, MD 21801


 
CHEST PAIN
 UNSPECIFIED, NON-CARDIAC DIAGNOSIS
DRG 143
Denials for FY 97/98: 30 days (15 due to non-acute level of care - 15 due to administrative)
PRMC Length of Stay: 1.84     State: 1.50
Per M & R Guidelines: Ambulatory

DOCUMENTATION TO USE
  • Document the suspected etiology of chest pain within the daily progress notes
  • Document your plan every day in your progress notes
  • Document daily disposition
  • Remember, on the inpatient side, suspected or R/O conditions qualify and may increase LOS
  • Signs and symptoms: type and duration of chest pain, constant or intermittent, location, radiation of pain
  • Arrhythmias and EKG findings
  • History of prior chest pain, MI, angina or CABG
  • Co-morbidities
  • Patient's functional status
  • "Chest pain 2° to esophagitis"
  • "Chest pain consistent with unstable angina"
  • "Chest pain due to GERD"
    • Will only optimize your acuity;
  • "Chest pain possible GI"
    • it will not ↑ your LOS.
  • "Chest pain non-cardiac"

WHY IS IT IMPORTANT TO CLARIFY DOCUMENTATION?
  • It will ↑ the severity of illness and improve Case Mix Index.
  • It will ↑ patient satisfaction by ↓ denial letters that patients receive.
  • It reduces physician's day-to-day interaction with payors.
Most common reason for DRG optimization is due to GI etiology.
Document discharge diagnosis in progress notes.
PTCA w/wo stent is an ambulatory procedure per M & R and Payors Guidelines.
M & R GUIDELINE EXPECTATIONS FOR DOCUMENTATION

       Documented Reasons for Admission:
  • Pain at rest
  • Nocturnal pain
  • Prolonged pain
  • High risk status
  • Inability R/O myocardial ischemia
        Inadequate Reasons for Admission –
       Outpatient Care, Office, Observation
       Unit, Urgent Care:
  • Non-cardiac chest pain
  • Pneumonia
  • Pleurisy
  • Esophagitis
  • Reflux