Documentation initiative increases case mix index

Staff collaborate with coders

A clinical documentation improvement program at Moses Cone Health System in Greensboro, NC, has resulted in a 6.43% increase in the case mix index and a 7.5% rise in the severity of illness weight.

The health system started the program two years ago when its risk of mortality rate was 35.9% higher than the average rate among hospitals in the state of North Carolina. At the end of the second year, the risk of mortality was 4.8% lower than the average for the rest of the state.

"We knew that our patients require comprehensive care and that our scores were not reflective of the severity of illness of our patients. Since our data are based on the final code assigned to the patient and the codes are based on physician documentation, we looked at ways to assist the physicians in documenting to capture the quality of care their patients need," says Mary Beth Brown, RN, BSN, CPHM, manager of utilization review of clinical documentation improvement.

The system hired four clinical documentation improvement specialists and implemented the clinical documentation improvement program in May 2006 at Moses H. Cone Memorial Hospital, the largest of four acute care hospitals. The initiative was so successful that the system increased the staff to six and implemented the program at a second and third hospital.

One of the new staff is dedicated to Wesley Long Memorial Hospital in Greensboro. The other is assigned to Annie Penn Hospital in Reedsville, which does not have as much volume as the other hospitals. When she completes her work at Annie Penn, she assists staff at Wesley Long.

The clinical documentation improvement specialists are experienced BSNs who are assigned to specific units, based in part by their clinical expertise and their knowledge of disease-specific criteria. The original four were utilization review nurses at the hospital and received additional training for their new role. One of the new team members already worked for the system.

"All of these nurses have clinical experience and some area of comfort. One has always worked on neuro units. Another has a cardiac background. Their background is very valuable when they speak with physicians or send them queries because their understanding of the disease process makes it easy for the physicians to relate," says Patricia Nourse, PhD, RN, BSPA, director of care management for the health system.

The clinical documentation improvement specialists are part of the case management department, which also includes case managers and care management assistants who are the communication link between the case managers and the insurers.

Nurse case managers handle utilization review and discharge planning as well as the discharge setup and referrals for home health, durable medical equipment, medication assistance, and transfers to long-term acute care facilities and inpatient rehabilitation. They are assigned by unit and have an average caseload of about 30.

Social work is a separate department and is responsible for psychosocial issues as well as skilled nursing facility and assisted living placement.

The clinical documentation improvement nurses are responsible for documentation.

If the payer is Medicare, the clinical documentation specialists complete an initial review within 24 hours and conduct a follow-up chart review every two to three days. They follow the patients through discharge. The initial reviews can take up to 15 minutes. The concurrent reviews involve only looking at a few days of additional information.

The hospital set a target of 32 episodes per day per clinical documentation improvement specialist.

"The staff exceeded our numbers so well during that first year that the hospital administration added two more clinical documentation improvement specialists," Nourse says.

The clinical documentation improvement specialists query physicians concurrently on both generic and diagnosis-specific query forms.

The team created a salmon-colored form on which the nurses write the supporting evidence they see in the chart and ask the physician if he or she agrees with a particular diagnosis, such as acute systolic heart failure or acute blood loss anemia.

For instance, a nurse might write: "The patient had a hemoglobin count of eight after surgery and received a transfusion of two units of blood. It's up to 10 now. Do you think acute blood loss anemia is the diagnosis?" If the physicians agree, they write "acute blood loss anemia" in the chart.

The form has a box on the bottom that the physicians can check if they agree and a place to write if they don't agree.

"The response rate has gone up since we gave them an easy way to respond," Brown says.

If the physician does not answer the written query, the clinical documentation specialist verbally queries the doctor.

When the physician responds to the query and enters the appropriate documentation in the record, the form is removed from the medical record. If there has been no response by the time the chart goes to the coders, the coders make a retrospective query to the physician.

The medical staff's performance improvement committee has collaborated to develop ways to frame the queries so it's easier for the physicians to understand what is being asked and easier for them to respond, Brown says.

In fact, the orthopedists have suggested integrating acute blood loss anemia in their chart documentation form.

"A conscious decision was made to talk to physicians about accurately reporting the risk of mortality, and severity of illness, rather than the dollar amounts connected with the higher MS-DRG," Nourse says.

"This has led to a lot more physician buy-in. The patient they're taking care of is their concern," she says.

When they review the record, the clinical documentation nurses enter their best estimate of the MS-DRG on the worksheet.

"When the worksheet comes back to the case management department, they can see the final MS-DRG assigned by the coders and see how accurate they were. It's a good educational tool," Nourse says.

The clinical documentation improvement specialists write the geometric mean length of stay for the working MS-DRG on the worksheet, giving the nursing staff, case managers, and social workers an idea of the expected length of stay.

"Nursing develops care plans based on the individual patient and how well he or she is doing. Being aware of how long the patient is likely to be in that bed, based on the best clinical estimate, helps with our length-of-stay efforts. It's also helpful to the case managers and discharge planners who are looking at the progression of the patients," Brown says.

Clinical documentation improvement leaders are collaborating with ancillary services to determine which questions need to be asked to ensure accurate documentation.

"One opportunity we frequently missed under the old DRG system was obesity vs. morbid obesity. We worked with nutritional services to develop a new form that includes body mass index and morbid obesity so we can document to accurately reflect the morbidity CC," Nourse says.