Communication key to improved documentation

Monitor your outcomes to measure success

Case management involvement in the documentation enhancement process can be limited to monitoring specific DRGs and collaborating closely with coding specialists to an environment where the case management department has staff whose entire focus is on documentation enhancement, asserts Lorraine Larrance, BSN, MHSA, CPHQ, CCM, manager with Pershing Yoakley & Associates, a Charlotte, NC, health care consulting firm.

How involved the case managers are depends on the hospital's philosophy, the other duties of the case management staff, and what the hospital wants to accomplish with the initiative, she adds.

When consultants guide a hospital through the documentation enhancement process, they typically review information provided by the hospital information system, conduct a chart review to validate the data, and identify opportunities for improvement, says Deborah Hale, CCS, president of Administrative Consultant Services LLC, a health care consulting firm based in Shawnee, OK.

"We ask the hospital to select clinical staff, usually nurses, who can be trained to take on the documentation enhancement project. We tell our case management clients that we are not trying to turn them into coders but we want them to use their clinical expertise to help make sure the documentation is clearly written in the medical record," she says.

Training is an important piece in the documentation enhancement process, Larrance points out.

Case managers need to have basic knowledge about coding principles, DRGs, and the reimbursement process to understand why it's important for documentation to be complete, adds Carol Eyer, clinical compliance senior manager with Pershing Yoakley & Associates' Atlanta office.

"Without this, the case managers are not thinking along the lines of reimbursement related to documentation in the chart. But with training, they can become the clinical extension to the health information management professionals to ensure that clinical documentation accurately depicts the patient's condition and treatment," she says.

When Eyer trains case managers on documentation enhancement, she presents classroom education, and then follows them through the process on the unit.

Before starting a clinical documentation improvement program, clearly define the scope of the process, and what you are trying to implement, Larrance says.

Identify what you are trying to accomplish, how you want to accomplish it, and where you want to focus, she adds. Clearly define the role of case managers in the process.

Among the options are having a specific group of case managers who do nothing more than documentation enhancement or including it in the duties of every case manager. Set out the relationship between the case managers and the coding staff. Consider whether you want the case managers to be solely responsible for the documentation enhancement piece or to develop a collaborative relationship with the coding staff.

A documentation enhancement program should be geared toward a hospital's payer mix, Eyer says.

"Where to focus on documentation enhancement parallels the same issues as looking at medical necessity or continued stays. Private payers may well have different medical necessity criteria or different agreements with hospitals, but there has to be a basic standard from which to operate," Larrance agrees.

If there is a heavy Medicare population, the program should focus on the Medicare guidelines from the Centers for Medicare & Medicaid Services (CMS). With a larger commercial population, the hospital may choose to focus some efforts on payer-specific guidelines, Eyer says. Many hospitals include patients covered by commercial payers as well as those covered by Medicare in their documentation enhancement projects, she adds.

"Medicare guidelines are often looked upon as an industry yardstick of sorts with managed care payers adopting similar standards," she says.

A lot of commercial payers are beginning to reimburse on the basis of the DRG payment, adds Doris Imperati, BSN, MHSA, CCM, managing consultant for Navigant Consulting, a consulting firm with headquarters in Chicago.

For instance, in New York state, many commercial payers are contracting with hospitals based on the Medicare DRG reimbursement schedule, she says.

Imperati suggests that hospitals initially concentrate on improving documentation for Medicare and other DRG reimbursement payers, and then expand the documentation improvement program to include all payers as soon as the Medicare documentation is going well.

"Initially, the improved documentation may only increase the case mix index and not the reimbursement with per diem contracts. However, if a hospital can show a higher case mix, which reflects increased patient acuity, the hospital may be able to use the higher case mix to negotiate a higher per diem reimbursement contract in the future," she says.

Start with a narrow list of DRGs to focus on, such as the top five problematic DRGs or the CMS core measure DRGs, which are reported as public data, Larrance suggests.

Case managers should educate physicians concurrently, reminding them through queries that written documentation can make a real difference in reflecting the severity of the patient's clinical picture.

"It's not an overnight change. The case managers must reach a comfort level to successfully assimilate documentation enhancement into their responsibilities," Eyer says.

Verbal inquiries to the physician save a lot of time and improve communication between the physician and the clinical documentation specialist, Imperati says.

"Ask them to explain what is going on clinically with the patient and then verbally query for clarification of their documentation in the medical record. It's tricky with compliance once you start putting queries in writing because you can't really have a dialogue about the patient's condition on a piece of paper. You have to always be careful so you are not leading the physician," Imperati says.

Some physicians tell Imperati "just tell me what to write."

This is a no-no, Imperati says.

"I tell them to just think about this case and write what is going on with the patient. I point out that the record should accurately represent the clinical nature of service and the care the patient received and the complexity of the patient's condition," she adds.

Try to steer away from the financial part of the equation when you talk to the hospital's physicians, Imperati advises.

"Otherwise, you're talking money and they're looking at patient care. It's better to keep them focused on documenting what they do for their patients in terms of quality because when the focus is on quality, everything else will fall into place," she says.

For instance, better documentation can improve a hospital's CMS report card, internal report cards, and report cards maintained by commercial payers because the improved documentation more accurately captures the severity of illness and helps to justify the length of stay and resource utilization.

"All doctors will tell you that their patients are sicker. We explain to them that our goal is to help them capture that in the documentation," says Imperati.

Imperati tells physicians that learning what to document in the hospital also can translate into better documentation in their office practice.

"Medicare is heading toward pay for performance for physicians in their office. Documentation improvement in the hospital gets them headed in the right direction," she says.

Encourage communication

When your project begins, encourage communication between the health information management staff and the case managers so the coders understand the goals and benefits of the program — and that case managers aren't interested in taking their jobs, Eyer suggests.

"Experienced coders often have considerable clinical knowledge and will welcome the opportunity to team with case managers to secure the documentation they so badly need in order to code accurately," she says.

Arrange regular meetings between the case management staff and coding staff to brainstorm on difficult cases and share successes, she adds.

After the training process, the hospital should measure whether the documentation enhancement initiative is making a difference, Hale says.

Monitor the hospital case mix index and top DRGs over time to determine your successes in capturing complications and comorbidities, Eyer suggests. Track physician compliance and physician feedback and communicate them to the appropriate people within the organization, including senior management and physician leadership.

Another way to measure success is to track the rate of the assignment of cases to a certain DRG after the training compared to baseline. The information is reported in your hospital's Program for Evaluating Payment Patterns Electronic Report data but case management directors may find it useful to track the data on a monthly basis, Hale says.

Look at the paired DRGs and track how many you report without complications or comorbidities. If your hospital ranks lower than your state's median, it indicates an opportunity for improvement, Hale says.

"With DRG-based reimbursement contracts, you can measure the financial difference from the moment the chart gets coded if the improved documentation puts the patient into a better- paying DRG," Imperati says.