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Documentation staff can alleviate CM duties
Separate, expert staff is needed
A few years ago, it was a common practice for case managers to be responsible for clinical documentation improvement along with their other duties, but that should no longer be the case, according to Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and partner and consultant in Dallas-based Case Management Concepts, a case management consulting firm.
"In today's healthcare environment, there's a limit to how many tasks you can add to the case managers' role and have them continue to be effective. We see clinical documentation improvement as a part of case management, but it should not be the responsibility of case managers. We recommend a separate role for clinical documentation improvement," Cesta says. "CMs can usually handle the clinical documentation in hospitals with 50 or fewer beds, but in larger facilities, they may struggle to juggle all the tasks they are asked to do. If your hospital has more than 50 beds, be very cautious about embedding the clinical documentation improvement function into the case management role."
Hospitals need staff dedicated to clinical documentation to fill in the gap between the documentation in the chart and what is being coded, Cesta says.
"Clinical documentation improvement is a complex issue that involves more than just looking at the chart, getting physicians to add more documentation, and hoping to get a better DRG. It's a very complicated and time-consuming process, and it should be handled by people with specialized expertise," she says.
When choosing clinical documentation staff, look for people with good communication skills who are self-starters, have critical thinking skills, are able to work independently, and have experience working with physicians, suggests Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital, and partner and consultant in Case Management Concept. They should know the clinical, coding, and compliance aspects of documentation, have an understanding of public reporting, and be able to articulate the purpose of the clinical documentation program to their peers and clinicians in other disciplines, Cunningham adds.
The clinical documentation specialists have to understand the MS-DRG process, how a CC (complication or comorbidity) and MCC (major complication or comorbidity) are extracted from the documentation in the medical record. They need to understand ICD-9 codes and what might increase the risk of mortality and severity of illness. They should have clinical credibility and be able to ask questions of physicians in a non-threatening way, Cunningham says.
Case managers make good clinical documentation specialists because they already have a good rapport with physicians, and that rapport is the key to a successful program, adds Doris Imperati, MSN, MHSA, CCM, associate director, Navigant Consulting, a consulting firm with headquarters in Chicago.
"Case managers know how to read a chart, and they're already familiar with admissions guidelines and continued stay guidelines. They know how to look for the underlying meaning of what the doctor is saying and get it into the chart," Imperati says.
At Stony Brook University Medical Center, the clinical documentation specialists are experienced case managers and work in the case management department. They are assigned by unit.
"We use nurses instead of coders because they have the clinical background to speak to the physicians," says Catherine Morris, RN, MS, CCM, CMAC, executive director of care management and clinical documentation improvement administrator at the Stony Brook, NY, facility.
When Medical City Dallas Hospital looked for opportunities for improving documentation, one of the areas the team identified was the oncology transplant unit.
"We identified the opportunity to increase documentation and severity of illness for these complex patients," Cunningham adds. As a result, the hospital hired a nurse practitioner with expertise in stem cell transplants to review the oncology service line documentation to ensure that it was complete and accurate.
Cesta says, "Educating the interdisciplinary team on clinical documentation improvement is a tremendous undertaking, and it's often more effective to call in a consultant who understands all the intricacies of the process."
Cunningham says, "When you interview consultants, get details on exactly what they are going to provide during the assessment process and as you go through the implementation process, and how they are going to follow up down the road." Find out what kind of software they have to help you track all the data you need to determine the effectiveness of the program.
Ask for references, and talk to people who have used the consultant, Cunningham recommends. Ask whether the consultant helped the department make the business case for more staff, how they worked with you during the implementation process, and how they helped you plan for education and training.