Like a detective, Pam Thomson probed the mysteries of CPT coding errors in the pulmonary medicine department at University of Virginia (UVA) Medical Center, looking for hard evidence of what went wrong and why. Were coding errors correlated with the time of day, day of the week, or workload? Was something amiss in the physician/coder interaction that produced the code? Were errors related to some fundamental misunderstanding of a specific type of code that caused consistent overcoding or undercoding?
After a lot of data analysis, Thomson, a nurse-turned-project manager, correlated errors to two main areas: (1) inadequate documentation for the CPT code that doctors use on admission day, and (2) coding for weekend patient encounters. So UVA revamped the pulmonary medicine coding process, increasing coder-physician face time so they can hash over trouble spots and shifting coders’ emphasis from concurrent physician coding to error-riddled physicians. A follow-up audit showed “near-perfect coding,” she says.
Just your everyday compliance-program experience? Not really. The path Thomson and her UVA colleagues took to untangling the riddle of the erroneous codes was paved by an approach to process improvement called Six Sigma. Pioneered by Motorola and also widely adopted at General Electric, Six Sigma is a data-driven method of identifying weaknesses in business functions, devising solutions and monitoring their continued improvement. It was embraced and evangelized at UVA by physician Thomas Massaro, M.D., chief of staff of the UVA Medical Center.
Six Sigma has five steps: define, measure, analyze, improve and control, says Thomson, a Six Sigma expert at UVA. These steps are taken to tackle very discrete issues.
“We have been struck by how small you have to get to attack and improve something,” Massaro says. “Six Sigma is the ultimate reductionist approach to the world. You get down to the genomic data file, the gene of a process, and what nucleic acids are involved in that. If you don’t narrow it to something manageable, you can’t get anything done.”
Massaro says the mechanics of Six Sigma are “not revolutionary.” But it is unique partly because it calls for “a more activist engagement by senior management.” Six Sigma “has been structured in a way that it is owned by executive management. This is the first time we have most senior people in the organization behind this, and we have a commitment to provide rewards and incentives that are consistent with behaviors in these programs. It is rigorous and the tools are powerful, but it works because people believe it will work.”
For example, each project has a team made up of a content expert and a program manager. The Six Sigma expert is called the Black Belt, and the person who is still mastering Six Sigma is the Green Belt. Massaro had to overcome resistance from some quarters because Six Sigma initially is not a money-making proposition.
UVA has Six Sigma projects underway in the following areas so far:
Each of these projects is tackled by a team with managers from relevant medical departments and content experts (i.e., internal audit, coding). GE trained UVA staff on implementing Six Sigma. Other medical centers, including Johns Hopkins in Baltimore, are hopping aboard the Six Sigma train, Massaro notes.
The coding Six Sigma project focused on physician fees for inpatient care. Here’s how UVA implemented it:
“The day [Pam] figured out the day of the week issue, there was a euphoria that was infectious,” Massaro recalled. “The difference is you get past the traditional form of anecdotes and speculation, and you have a bunch of numbers that come together using mathematically precise techniques.”
One thing Massaro and Thomson have learned is that Six Sigma will reveal all sorts of things about people and processes they never anticipated. For example, when they surveyed physicians about improving billing and coding, Massaro and Thomson assumed they would hear physician gripes about not getting paid enough or the burdens of coding and documentation. But instead, physicians focused on making bills more understandable to patients, and the understandable-patient-bill project was born.
“That was a huge revelation to us,” Thomson says. Physicians, they speculate, don’t want to waste time answering patients’ billing questions about their Rube Goldberg-like bills, and perhaps don’t want to appear stupid to patients because they can’t answer them. “So we drilled down further to find out what patients don’t understand about their bills, and had another revelation:” mistakes on the bill, such as an inaccurate diagnosis, prompted most patient calls about billing – not confusion or bafflement. Thomson says it was a welcome insight because they can fix those errors.
“That was a total ‘Aha!’ for me,” Thomson says.
And it “taught us the power of the data to show us the truth,” Massaro notes. “Before we did it on instinct in terms of picking projects and the scope of projects.”
About The Article
This article has been reprinted with permission from the REPORT ON MEDICARE COMPLIANCE, the nation’s leading source of news and strategic information on false claims, overpayments, compliance programs, billing errors, and other Medicare compliance issues. For more information read the REPORT ON MEDICARE COMPLIANCE.