CE, communication keys to successful initiative

Nurses, coders meet monthly, collaborate daily

Ongoing education between the clinical documentation improvement specialists, the coders, and managers of each department is essential to the success of Moses Cone Health System's clinical documentation improvement initiative, says Mary Beth Brown, RN, BSN, CPHM, manager of utilization review of clinical documentation improvement.

The clinical documentation improvement specialists and coders meet each month to educate each other and collaborate on ways to improve the program. Management of the care management and medical records departments communicate frequently about the accuracy of the MS-DRG assignments and meet monthly to identify educational opportunities to discuss at the monthly joint team meetings.

But it doesn't stop there.

"We don't wait until our monthly meeting when an issue arises. We keep the communication flowing and share educational opportunities with the staff. It's important that our staff get feedback immediately, rather than waiting a month or two," Brown adds.

For instance, when the worksheet is returned to the care management department after the final coding, the clinical documentation improvement specialists review it to see how closely the MS-DRG selected by the coders matches the initial input.

If there is a discrepancy, Brown pulls the chart and reviews it with the staff to educate them on what they might have missed. If there are questions, she sends a query to the medical records manager.

All of the newly developed disease-specific query forms receive a final review by the clinical resources management committee to determine if the questions being asked are clinically appropriate. The results are used for educational opportunities with the staff, adds Patricia Nourse, PhD, RN, BSPA, director of care management for the health system.

The departments compile the data and share them with the physician staff, she adds.

"We can look at which service lines receive the most queries and which are responding and can even look at queries and responses by individual physician," Nourse says.

The clinical documentation improvement team, which includes the clinical document improvement specialists and the coders, attended training four hours a day for three weeks.

After training, the concurrent reviews and nurses met every two weeks for the first year of the program.

"The nurses learned about coding and the coders learned about the clinical aspects of the case. Whenever what we saw as clinicians didn't match the final code, we used that as an educational session," she says.

"Meeting with the coders has been a very good learning experience. We present the clinical picture and the coders tell us what is important. The education back and forth has been phenomenal," Brown says.

The implementation of the new MS-DRGs pose a real challenge to the nurses and coders because it requires more extensive documentation than the DRG system in order for the record to accurately reflect patient severity.

For instance, documentation for congestive heart failure as a secondary diagnosis has to be very specific in order for the hospital to get the appropriate reimbursement for the services the patient received, Brown points out.

"The clinical documentation improvement specialists deal with what the words are and the coders deal with the numbers. Because we had a close working relationship with the coders, we have been able to learn the new system together. The monthly dialogue has helped a lot to clear up any questions," she says.

As part of the transition to the new system, the team developed an online tool that crosswalks the DRG codes and requirements with the corresponding MS-DRGs.

"For instance, if we know a patient has renal failure, we can determine the MS-DRG, the alternate MS-DRG based on complications and comorbidities, and compare it to the DRG," Nourse says.