Medicare Revenue Enhancement and Consultation-Liaison Psychiatry

Consultation-Liaison (C-L) psychiatric services are generally not profit-making enterprises. Indeed, they are hard-pressed to demonstrate that they break even. Some attention has been paid to this issue in the recent literature, and specific recommendations of a most helpful nature have been made. The C-L service at Lehigh Valley Hospital (LVH) in Allentown, Pa., where I am employed, has implemented many of these recommendations. And, as presented in this article, we have expanded on some of these recommendations.

LVH is a tertiary care hospital servicing a five-county area in Northeastern Pennsylvania. It contains a shock trauma unit, burn unit, medical and surgical intensive care units, and an acute coronary unit as well as a variety of step-down units. There is a very active oncology service and cancer center, offering services that include bone marrow transplantation. The C-L psychiatry service consists of three psychiatrists who attend to the needs of this busy institution. Like many other services of this sort, C-L psychiatry is under increasing pressure to demonstrate added value to LVH.

One method selected in order to achieve this goal is to demonstrate how our C-L service enhances the revenue stream into LVH. This is readily measured, and attracts the attention of hospital administrators much more effectively than do efforts at quantifying patient satisfaction or quality of care.

We have all learned to live in a world of DRGs that provide a fixed rate of reimbursement to a medical institution for a given diagnosis. This reimbursement can be enhanced if certain comorbid conditions, some of which may be psychiatric diagnoses, are identified. As an example, in 1994, the Medicare reimbursement for a digestive malignancy (DRG 173) was $1,967.26. If a comorbid condition was identified, the reimbursement becomes $4,026.90. Table 1 represents the list of mental disorders that constitute comorbid conditions with their ICD-10 coding numbers.

At LVH, we performed a chart audit for 1994, looking at some 70 charts of Medicare patients to identify potential DRG enhancements that had been missed. We discovered that 35% of those charts contained evidence to support one or more psychiatric diagnoses that would have represented additional revenue to LVH. To demonstrate C-L psychiatry's added value to LVH, we designed a presentation to educate the medical staff on one of these diagnoses. This structured educational intervention was put together through the joint cooperation of C-L psychiatry, the coding people in the medical records department and the finance department.

The educational presentation was designed for the general medical staff and focused on delirium, although other material was included as well. A definition was provided to give the staff a framework. The goal was to teach them to think about delirium as having a differential diagnosis-modeled after that for pneumonia. Specific examples taken from the medical records coding handbooks were used to demonstrate the importance of concise and clear language in documenting delirium in a patient's medical record. These presentations were given to each department in the hospital. It required 18 months to accomplish this task, due to the logistics of scheduling the 15-minute mini-lectures.

We then measured the results of this educational intervention. Our baseline information on DRGs with possible psychiatric-related comorbid conditions had been collected from records between Jan. 1, 1994, and April 30, 1994. We then compared those records with records from Jan. 1, 1996, through April 30, 1996, after the educational intervention was completed for the entire medical staff.

Table 2 summarizes the results. The number of identified cases increased from nine to 52. Another interesting effect is that psychiatric consultations on these cases increased from four to 36. The revenue enhancement from the correct identification of these comorbid conditions increased from $21,878 to $130,952. We have continued to follow this data into the present fiscal year. Although 1998 data has not been totally compiled as yet, we do see the effect begin to tail off in the second year following the intervention.

Beyond fiscal consequences is the more difficult-to-measure issue of improvement in patient care. The key to management of delirium is the identification of its cause. The data seem to suggest that if delirium was recognized and discussed in the medical record with relation to possible cause more frequently, it would be managed more effectively. Our study did not measure this, although I assume it to be true. Certainly that would be the expected outcome in the cases where C-L services were consulted.

This is the first study of which we are aware that was done in the real world, demonstrating the benefits of a C-L service using real dollars. The improvement in quality of care for patients is more difficult to measure, but is an expected outcome as well.