Critical Path Network

Team approach to improving documentation pays off

CMs, documentation specialist work together closely

A team approach to documentation enhancement has resulted in a reduction in accounts receivable days, more accurate billing, and dramatic decreases in the number of queries to physicians for clarification about documentation at the Catholic Health System of Buffalo, NY.

The documentation enhancement initiative is a joint effort involving the medical staff, care management, medical records, billing and coding, and mentored by documentation specialists, registered nurses with a background in case management.

Lower accounts receivable days mean that claims are being processed without challenge or barrier.

The hospital system developed an initiative it called Teaming for Documentation Integrity (TDI) and created a work group to develop a process to ensure that documentation and subsequently coding and billing were accurate.

"We knew that whether we were looking at the system as a whole or each separate entity, correct documentation was critical for acute and post-acute coding and billing," says Dee Cooper, RN, BSN, CCM, CCUM, director of care management for the four-hospital system.

"The TDI effort began with a review of Medicare-benefited patients and has progressed to a review of managed Medicare-benefited patients. However, the improvement of clarity of documentation has been realized throughout the system, regardless of payer," Cooper added.

When a patient is admitted, the RN case manager performs an assessment and opens the patient chart. The case manager is the captain of the care coordination team in collaboration with the social worker who handles discharge planning and the RN discharge coordinator, who handles discharge planning and post-acute needs.

The case manager's primary functions are to validate inpatient admission status, closely monitoring the services and the time of processes to meet the hospital system's goal of having a definite diagnosis and plan for discharge in place within 23 hours of admission.

The case manager reviews the patient presentation, the physician's initial progress notes, inpatient vs. observation status, and follows InterQual criteria to determine the intensity of services the patient is likely to need.

The documentation specialist follows up to review the medical record for the primary diagnosis, then goes over the initial documentation to ensure that it is clear and supports the diagnosis.

For instance, the chart may indicate that a patient is receiving infusion and has abnormal lab values and hypothermia. If the patient had a blood culture performed, the documentation specialist concludes that the physician may be considering sepsis as the source of illness.

The documentation specialist follows the record to see the results of the blood culture and makes sure that sepsis is noted on the chart if appropriate. She mentors the physician to assure validation of the diagnosis or to ensure that the physician changes the admitting diagnosis based on the laboratory results.

"If the documentation is not clear and the lab work doesn't support the coding, the documentation specialist queries the physician asking for the diagnosis to be clarified," Cooper says.

Depending on the length of stay, the documentation specialists may review the charts two or three times, monitoring the documentation to make sure that it meets criteria and includes all the documentation needed for coding and billing.

The documentation specialists write their queries on brightly colored paper inserted into the physician progress notes to alert the physician that there is a question.

The physician may write a note on the query sheet in addition to clarifying the documentation in the patient record.

The colored sheet is a communication tool and does not remain with the record once the documentation query has been addressed.

The care management staff in the health system operates under a geographic model. Each unit has at least one RN case manager, one discharge coordinator who is an RN, and one social worker. The documentation specialists typically cover more than one unit.

The largest hospital in the system has 302 beds and sees 40,000 patients a year in the emergency department. There are three full-time documentation specialists at that hospital, assigned by unit.

"They cover the same units all the time. This helps them in building a relationship with the physicians," Cooper says.

The case managers oversee the rest of the team to make sure the patients are moving as they should through the continuum.

"We try to break down the walls between the different roles. The team meets every morning and discusses the patient progress with the charge nurse and the medical staff as appropriate. Depending on what each patient's needs are, the social worker may take the lead, or it may be the discharge coordinator who is putting together the home care or rehab referral to CHS providers," Cooper says.

The hospital system began its documentation enhancement initiative in 2002. The first step was to create a workgroup with representatives from the medical staff, care management, medical records, billing, and coding.

The team reviewed the patient care processes at the hospital and looked at ways to make sure that documentation was correct in every patient chart. They identified trends in gaps in documentation, such as how physicians were looking at the patient's diagnosis versus how the coders were able to code it using the documentation in the chart.

"We as an organization needed to look at what information was out there and work with our physicians to develop a criteria or a documentation expectation that clearly validates that diagnosis," she says.

The first phase of the documentation enhancement project took six months.

The team developed tools for the documentation specialists to use when they were querying physicians. The tools include information that the coders use in identifying certain diagnoses, which helps the documentation specialists ask the right questions.

"They are responsible for everything from admission status to clearly identifying the primary diagnosis. The documentation specialists had to learn not to direct a physician into a specific DRG but to query as to what the physician means by what he writes on the chart," she says.

The hospital brought in external sources to provide training on medical criteria and coding.

"Whether they're looking at the chart or billing the insurer, everyone needs to understand the criteria set," she says.

The team took six months to lay the groundwork for the new process. Much of the time was spent educating the physicians about both the processes and philosophy of the model.

"We knew that if we pulled together, with all parties involved in understanding the implications of the new procedure that we would be successful," she says.

The team educated the medical staff on how to understand how the process would flow. They covered who the documentation specialists are, their backgrounds, their roles, and how they interact with the coders and the medical billing staff.

"The six months was well worth the effort. We needed to educate the physicians on the purpose of the initiative and to get their feedback in terms of what kind of queries they preferred," Cooper says.

The team continues to educate the incoming physicians at the health system's two teaching hospitals. Interns and residents go through an inservice training program right from the beginning to make sure they understand not just the process but also the purpose behind it. The documentation specialists periodically prepare "storyboards" which are placed in physician lounges and other places throughout the hospital to further educate and mentor the physicians.

The physician leadership, infectious disease doctors, nursing leadership, medical records leadership, financial management, and case management leadership at the four hospitals meet at least quarterly to review how the documentation enhancement process is working.

"The goals of the Teaming for Documentation Integrity initiative directly support the system's quality and compliance efforts through accurate coding of the DRGs, supported by clear documentation in the medical records," Cooper says.

The hospital system began its fourth year with the process in July. When the system implements the paperless medical record system, which is in the works, the care management documents will contain an electronic alert for physician queries.

The health system, which serves Buffalo and its surrounding counties, was formed in 1999 from a group of hospitals that were operating independently.

"It was a cultural change for a long-standing organization. We had two case management models — acute case management and community case management — and two directors," Cooper says.

As part of the redesign, the case managers started using wireless laptop computers with a software program to support acute care, discharge planning, and post-acute needs.

For more information, contact Dee Cooper, RN, BSN, CCM, CCUM, at e-mail: