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Does your documentation assurance program stop short?
Make sure the record is complete to accurately report mortality data
If your documentation assurance program focuses on reimbursement alone, you're not going far enough. With pay-for-performance initiatives on the rise and increasing mandates for public reporting of hospital data, it's critical that the medical record accurately reflect the severity of illness and the services provided to your patients.
Many times, documentation specialists do a great job of picking up the complications/comorbidities (CCs) and major complications/comorbidities (MCCs) but stop right there and miss the opportunity to add additional documentation, which will affect the drivers of acuity level and risk of mortality. Bert Amison, managing director of health care advisory services for KPMG LLP, who works with hospitals on documentation improvement projects, says he has found this to be true.
"So often, hospitals concentrate so much on reimbursement that they put other issues on the back burner. Many times, when we conduct an analysis of hospital documentation, we find little or no opportunity on the hospital reimbursement side, but there is a lot of opportunity on the risk-adjusted mortality side," Amison says.
The MS-DRG system is somewhat severity-adjusted, but it still doesn't give a comprehensive picture of how severely ill the patient is, adds Tamara Hicks, RN, BSN, CCS, manager of care coordination at North Carolina Baptist Hospital in Winston-Salem, NC.
This means it's no longer enough just to get the MS-DRG correct and ensure that your hospital is appropriately paid for the services it provides, she adds.
Often just one comorbid condition will put a patient into a higher-paying MS-DRG, but if the patient has multiple comorbidities, it can affect the hospital's severity of illness data, Hicks says.
"When we first started our documentation integrity program, we looked only at Medicare patients and their DRGs. When we got a complication/comorbidity documented, we stopped because we had gotten the patient in the highest-paying DRG. But if there is a patient who is in the ICU for 50 days and we document only enough for the highest reimbursement, it skews our severity of illness and expected mortality data," she says.
When the administration asked for data that showed how sick the patients really are, the care coordination department evolved its documentation integrity process to ensure that the documentation gives a complete picture of the patients' condition and services received, Hicks says.
Draw complete picture
"It's important for the documentation to be complete. If a patient dies while in the hospital, we want our data to show that we expected it. We don't want the record to show that the patient had only a 10% chance of dying because the documentation was not complete," she says.
Web sites such as The Leapfrog Group and Health Grades include expected mortality and the mortality index in their hospital report cards, says, Liz Youngblood, RN, MBA, vice president, patient care support services at Baylor Health Care System in Dallas.
Documentation that accurately shows severity of illness and mortality data is more critical than ever because so many decisions are being made based on administrative data, she adds.
Patients are starting to shop for health care and may use public report cards in their decision-making process, Youngblood says.
"Consumers are becoming more savvy and more active in making decisions about their health care. They no longer rely solely on their physicians when it comes to choosing a hospital. They are looking on the internet and asking a lot of questions," she says.
The data also affect the hospital-specific assigned base rate with which Medicare reimbursement is calculated. Quality information that is based on administrative data also may be considered during the negotiation of managed care contracts, adds Youngblood.
Commercial insurers are focusing more and more on quality of care and are taking comparative data into account as they contract with providers, she says.
Managed care payers have claims data as well and can use the information to analyze hospital outcomes of care, Youngblood adds.
"Providers with more favorable outcomes may be considered the best choice for payer populations," she adds.
For instance, The Leapfrog Group's Hospital Rewards Program ranks hospitals in four tiers, based on quality measures and resources use, allowing commercial insurance and employer groups to use the information for pay-for-performance initiatives.
Reporting accurate mortality data is important as Centers for Medicare & Medicaid Services moves toward value-based purchasing and begins to tie reimbursement to quality indicators, Amison points out.
"The trend is going in the direction of possibly tying more payments to hospitals who report more appropriately and more accurately," he adds.
Mortality reporting, severity of illness, and risk of mortality all are driven off of coding. This means the documentation in the medical record should be complete and accurate to fully reflect the patient's condition, Hicks says.
Documentation assurance makes sure you are paid appropriately for the care provided by ensuring that you have the documentation in place to support medical necessity. Additionally, other rules, such as whether a condition was present on admission, must be clearly documented to allow coders to appropriately code, Youngblood says.
"It's really about compliance — making sure that you have accurate coding, and that entails making sure you have the proper documentation in the medical record," Youngblood says.
Whether your department is starting a brand-new program or beefing up an existing program, you need to be able to demonstrate a business case for documentation assurance in order to sell it to management, Amison says.
Return on investment
"Return on investment for a documentation assurance program is very real, especially when Medicare and Medicaid are proactively looking to recoup funds through the Recovery Audit Contractor and Zoned Program Integrity initiative," Amison says.
"A proactive and robust documentation improvement program produces a financial return on investment, a compliance return on investment, and appropriate documentation of the severity level of patients," he says.
Start by pulling together a multidisciplinary team to evaluate what the program might look like, Amison suggests.
In addition to case management, the health information management director, the quality and/or compliance officer, the chief financial officer or a representative from finance, and the chief medical officer or the chief nursing officer or both should be on the team.
"The team should include representation from every department that has a stake in documentation assurance. If people are involved from the beginning in the evaluation process and the creation of the program, they're more likely to be involved and promote the program with their staffs when it is rolled out," Amison says.
The team should review the medical record and the coding to determine where the documentation deficits are and where there is room for improvement, Youngblood suggests.
Don't concentrate on every MS-DRG at once. Pick a few areas where you can make the biggest difference, she advises.
Don't assume that the areas other hospitals struggle with are the same areas where you should focus. All hospitals are different, Amison adds.
Amison strongly advises his clients to dedicate full-time staff to a documentation improvement program.
"The solution isn't just to put the documentation improvement process on the case managers' plate when they typically have more pressing things to do. If you take into account all of the benefits of a documentation assurance program and compare that to the salary for dedicated staff, it's a no-brainer," he says.
Before beginning the program, educate everyone who is going to be involved in the process.
Take a three-pronged approach to education, Amison suggests.
"You can't educate the documentation specialists and the coders and not the physicians," he adds.
(For more information, contact: Bert Amison, managing director of health care advisory services, KPMG, e-mail: email@example.com; Tamara Hicks, RN, BSN, CCS, manager of care coordination, North Carolina Baptist Hospital, Winston-Salem, e-mail: firstname.lastname@example.org; Liz Youngblood, RN, MBA, vice president, patient care support services, Baylor Health Care System, e-mail: email@example.com.)