Documentation project increases case mix
Documentation project increases case mix
Initiative to capture comorbidities, complications
Before Mountain States Health Alliance began its documentation improvement project, an outside consulting firm reviewed the hospitals' records and estimated that the Johnson City, TN-based hospital system had the opportunity to increase reimbursement by $5 million to $6 million annually with a documentation improvement program.
It's too soon to have any cost-saving statistics, but since the documentation improvement program began on July 1, 2006, the case mix index has increased by as much as 8.3% at some of the hospitals, according to Debbie Cook, RN, director of patient resource management for the health care system.
As patient resource management director, Cook is responsible for case management and social services at each hospital.
Before the hospital system started its documentation enhancement program, Johnson City Medical Center's case mix index was very low compared to facilities of similar size.
"We knew we couldn't be treating patients that were any different from those at the hospital down the street but their case mix was a lot higher than ours. This represented an opportunity to improve documentation so that the medical record clearly describes the patient illness," she says.
The administration made the decision to have the case managers spearhead the documentation enhancement project.
"My philosophy is that the case managers are the key people who can take on the documentation enhancement process. They're already in the charts and they already have a relationship with the physicians," she says.
The hospitals in the Mountain States Health Alliance have a physician-based case management model.
"The case managers are already working with the physicians on a daily basis. They have a rapport with them and are in a good position to educate the physician on what documentation is needed," she says.
The hospital administration considered adding RNs who were dedicated documentation specialists and decided against it, Cook says.
"That would mean there was another person that the physician had to deal with on a day-to-day basis. The case managers were in the best position to take on documentation enhancement," she says.
At Johnson City Medical Center, the organization's flagship hospital, her staff include RN case managers, social workers, LPNs who assist in discharge planning, a staff in charge of commercial payer precertification, and clinical appeals and denials staff who handle all appeals. "A good case management department can handle a multitude of roles, but there have to be enough staff to get it done," Cook says.
In order to ensure that the case managers had time to take on the additional duties, she set out the key responsibilities for case management — those were admission and continued stay, resource management, documentation improvement, quality, and supervising the discharge plan.
"We determined from the start that case manager caseloads needed to be between 20 and 25 for them to be able to handle all these tasks and do them well. We hired more staff and had the social workers and precertification staff assume a few more responsibilities," Cook says.
She shifted some of the case management duties, such as the majority of discharge planning tasks, to the social workers.
"We gave the case managers the responsibility for supervising the discharge plan. They passed on information they gathered when they interviewed patients to the social workers but the social workers assumed must of the discharge planning piece," Cook says.
The hospital system hired Pershing, Yoakley & Associates, a Charlotte, NC-based health care consulting firm, to provide classroom and on- the-job training for the case management staff.
"We considered hiring an external company to come in and take care of the entire program but we felt we had enough resources internally to put together our own program," she says.
Case managers from all the hospitals in the system came to Johnson City Medical Center three days a week for four-hour classroom sessions. Staff from the consulting firm shadowed them in the afternoons as they worked on documentation enhancement while performing their usual case management duties.
The hospital system arranged to videotape the training sessions to be used in ongoing training with new staff to give them basic information.
Following the training, the hospital system hired a documentation improvement specialist, with a background in coding and medical records, who works corporationwide and rotates between hospitals, providing training for new employees and conducting ongoing training for case managers.
"When external programs come in and provide training and software, what you don't get is ongoing education unless you pay for it. We wanted someone on board who could train new employees and keep everyone up to speed on changes in documentation requirements," Cook says.
In addition, the hospital purchased coding tools and other resources for each case manager's computer as well as reference books.
Before the project started, the case management and finance department worked together to come up with areas on which to focus. The hospital purchased Medicare Provider Analysis and Review (MEDPAR) data and benchmarked the hospital system's data against those to set goals for the project.
"We separated the data into service lines and looked at our rate of capturing complications and comorbidities [CCs] compared with the national database. We wanted to know where we ranked as far as case mix index compared to other hospitals," she says.
One of the main goals of the project is to concentrate on making sure that any comorbidities and complications are documented in the chart so that a higher DRG can be assigned, if appropriate.
When the case managers review the medical records for admission status and continued stay, they assign an initial DRG on their own worksheet based on the documentation, along with what they think the DRG could be based on the clinical information on the chart.
CMs, coders should work together
The case managers and coders meet once a month to talk about cases and why they should be coded a particular way. The coding staff attended some of the training sessions so they would be familiar with what the consulting firm was teaching the case managers, Cook says.
"Medical records and coding are key pieces in any documentation enhancement initiative. We had them on board from the get go. We have developed a wonderful relationship with our coding staff and call on them on a regular basis. We, as nurses, have something to offer them in terms of our clinical knowledge and expertise. We don't profess to be coders but we have the basics under our belts," she says.
Because the case managers are assigned by physician and specialty, each case manager doesn't have to learn all of the documentation required for every DRG. They learn the basics of coding and concentrate their efforts on their particular specialty.
The case managers review the documentation for all their patients, regardless of payer.
"So many payers are moving to a DRG-based payment system that it's hard for us just to look at Medicare patients. When the case managers are looking at the chart, they aren't thinking of what kind of payer is involved. They are just thinking of improved documentation. We apply the same documentation improvement standards for all patients," she says.
Before the initiative began, the hospitals' physician advisors met with the physician groups and explained the documentation improvement program, its goals, and why the hospital was undertaking it.
The case managers also conducted one-on-one training with the physicians.
"The physicians concentrate on providing care for the patients and they rely on the case managers to help prompt them to follow all of the coding rules," she says.
For instance, the term "poorly controlled diabetes" can't be coded. It needs to be written "out of control diabetes" on the chart.
When case managers have questions about documentation, they talk to the physicians face-to-face whenever possible. Otherwise, they post the questions on a special query sheet that they insert in the patient chart. The social workers also use the query sheet to leave notes for the physicians.
The query sheet is not a permanent part of the patient record. However, Cook uses it to compile data on physician compliance, whether they answer the queries and whether they agree or disagree with the case manager's suggestions.
Cook also tracks the number of DRGs with complications and comorbidities and breaks the data shown by physician specialty. She monitors the case managers and compiles data on the number of queries they make.
The hospital system monitors the difference between the final code by the coder and what the case manager thought the code would be to identify opportunities for education by the documentation improvement specialist.
Before Mountain States Health Alliance began its documentation improvement project, an outside consulting firm reviewed the hospitals' records and estimated that the Johnson City, TN-based hospital system had the opportunity to increase reimbursement by $5 million to $6 million annually with a documentation improvement program.Subscribe Now for Access
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