Documentation program nets hospital $1 million

Coders work with CMs on documentation

A documentation improvement program in which care managers and coders work as a team resulted in an increase in revenue of more than $1 million in 2005 for United Health Service Hospital in Johnson City, NY.

"By making sure that everything is documented accurately, we're getting credit for what we're already doing. We're already giving the patients these services and supplies, but now we're documenting and coding it, and that results in more reimbursement," says Nancy Rongo, CNAA, BC, CHCQM, director of care management and medical social work.

Each day, two documentation enhancement coordinators, trained medical coding specialists, go to the hospital units and review the charts. They are assigned to specific units and work with the care managers on those units to ensure that the physicians are documenting the complexity and intensity of the services provided.

The coders are specialists in knowing what needs to be documented in order for the hospital to be reimbursed appropriately and what procedures and conditions can change the DRG of a patient. The care managers have the clinical knowledge to discuss any documentation problems with the physician, Rongo says.

"The coders and care managers work together as a team. No matter how much training care managers have, they don't have the kind of detailed knowledge that coders have, but they are in a position to prompt physicians with questions about the patient's condition and plan of care," she adds.

In addition to increasing revenue to the hospital, the documentation enhancement program helps justify medical necessity and length of stay, assists in appealing denials, and has improved the hospital's comparative data by accurately reflecting the complexity of the patients being treated, Rongo points out.

"When documentation is not complete, it's a double-whammy. Not only does the hospital lose revenue opportunities, but when you look at comparative data, it appears that the hospital is charging a lot more for cases that are less complex than those at other hospitals," she adds.

If the hospital's cost and mortality are high, it may be because the comorbid conditions are not documented. This may appear to be a quality of care issue when actually it is a documentation problem, Rongo notes. "The reality is that the complexity of our patients was greater than it seemed, but because of documentation, our data didn't show it before we started the documentation improvement project. If it's not in the chart, you can't code it," she says.

Under the documentation improvement system, the additional documentation that is needed is added to the charts concurrently, rather than after the patient is discharged and the chart is sent to the health information department to be reviewed by the coders.

"With the old system, there were times when we couldn't question the documentation because the chart was already complete. Now we do it concurrently and document why the patient is in the hospital and the complexity and intensity of services," says Michele Rando, concurrent documentation enhancement coordinator.

Utilization review

Physicians respond better when the care managers raise the questions concurrently, rather than when the coders raised the questions after the patient was already discharged, Rongo adds.

"When a new patient comes onto the unit, the care manager attaches a "Problem List," a one-page sheet, to the patient's chart and uses it to make notes on areas of concern.

When the care managers conduct utilization review, they make a note of any problems or questions that need to be addressed during the patient stay or anything that is in the patient's history. The coder reviews the list, looks at the medical records, and identifies the kind of questions the care manager should be asking the physician and notes them on the problem list.

For instance, a patient is admitted with pneumonia and the chart shows that there is a positive sputum culture for Staphylococcus aureus and that the physician changed the antibiotic treatment, following the positive culture. Rando writes a query on the chart for the care manager to check with the physician to see if the pneumonia was caused by the organism and to enter it on the chart. As a result, the diagnosis changes the DRG to one that receives a higher reimbursement.

Rando reviews between 60 and 90 charts a day, depending on how many patients are on the units she covers. The system allows her to track and report how much revenue was generated by the enhanced documentation.

"We compile a list of documentation that is added based on the concurrent review and to track the dollar amount that the correct documentation generated," Rongo says.

The team approach works well, she points out.

The care managers are clinicians who understand the medical aspects of the patient's condition.

The coders have expertise in coding with knowledge of the codes and coding guidelines. They have a two-year associate's degree in health information management, then sit for an examination to become certified as a registered health information technologists (RHIT) and complete 20 hours of continuing education for a two-year period.

"The coders have an entirely different body of knowledge from the care managers. Coding and documentation is a specialized area, and I didn't feel it was appropriate for the case managers to invest that much energy into a complicated process, which might divert them from their core duties. The coders help us discern what documentation will make the coding more accurate and result in higher reimbursement," she says.

The hospital started its documentation improvement program in 2001 by bringing in a consultant to educate the physicians on how to document more accurately. "We had looked at our risk assessment and felt that we weren't capturing all the comorbid conditions. We wanted to improve documentation in order to increase reimbursement, assure documentation of medical necessity, and improve how we compare with other organizations from a data perspective," she says.

Rongo calls the work with the consultant "moderately successful." "It created some additional awareness. We focused on taking education to the care management level and having the care managers work with the physicians as quasi coders," she says.

The coders and the case managers met to determine opportunities for improvement in documentation and designed a pilot project for one unit.

During the project, a coder came onto the unit and worked with the care managers to identify comorbid conditions and other symptoms that could affect the coding.

During the three-week pilot on the orthopedic unit, the case management-coding team was able to show that its efforts increased revenue by $33,000 just by documenting and coding accurately the complexity and intensity of services provided. For instance, if a patient received a blood transfusion, the coder asked the care manager to inquire of the physician the reason the patient got the blood.

Adding anemia or postoperative blood loss as a complication of surgery results in a bigger reimbursement. "In total, those subtle changes in documentation can dramatically increase revenue," Rongo says.

Following the success of the pilot project, the hospital gradually expanded the initiatives to more units.

In 2003, the documentation enhancement resulted in $650,000 in additional revenue. By 2005, the total was more than $1 million in increased revenue generated just by the documentation enhancement project.

The documentation enhancement program has been well received by the hospital's attending physicians, Rongo says. "Physicians are increasingly concerned about how they look when it comes to comparative data. The care managers are able to tap into this and educate the physician that if they don't document clearly that they are treating a complex patient, it will appear that he or she is treating less complex patients compared to the peer group."

The quality management department gives physicians risk-adjusted comparative reports, allowing them to see the effects of documentation both internally and externally. "The care managers tell the physicians that improved documentation will give them credit for the type of patients they are treating. The physicians also understand that the better the clinical documentation, the better chance we have to successfully appeal denials," she says.

The hospital's nurse care managers report that many of the physicians find the problem list on the chart to be helpful, especially when they are covering for another physician and because it provides them with a view at a glance of everything that is going on with the patient. Some physicians use the problem list when writing their discharge summaries.

The hospital is conducting a pilot program using a new problem list that includes information on the DRGs covered under the post-acute transfer rule from the Centers for Medicare & Medicaid Services that went into effect last October.

The new list includes the working DRG and the geometric mean length of stay for that DRG.

"We want our care managers to have an awareness of which DRG is likely to be a transfer DRG and the geometric mean length of stay for that DRG to help them in managing the care of the patients and moving them through the continuum safely and efficiently," Rongo says.