Documentation program helps avoid revenue loss

Physician education, standardized prompts key

When the Centers for Medicare & Medicaid Services (CMS) unveiled the new MS-DRG reimbursement system in 2007, a data analysis projected that Sharp Chula Vista Medical Center was likely to lose about $500,000 with the new system, based on the hospital's 2006 data.

After a series of initiatives to improve documentation and capture of complications/comorbidities (CCs) and major complications/comorbidities (MCCs), the 330-bed hospital in suburban San Diego actually experienced an additional $2 million in revenue.

The hospital advisory board conducted an analysis of the new MS-DRG system, which showed that the hospital was likely to take a financial hit when the new reimbursement system was implemented if changes weren't made, says Cheri Graham-Clark, RN, MSN, PHN, director of quality improvement and care management/patient safety officer.

Sharp began its MS-DRG initiative as soon as CMS announced the new reimbursement system.

Projects included an extensive education program for physicians, including packets of information for each service line, standardized query forms for physicians, and the addition of a clinical documentation specialist position to the staff, says Susan Payne, RN, BSN, CPHQ, CPUM, manager, case management/social services. The clinical documentation specialists report to the manager of case management.

The hospital appointed an MS-DRG committee that worked with the physician advisor to case management, the health information management manager, and the manager of care management to develop ways to educate the physicians.

Educational materials created

The team created a story board that they shared at a physician expo, wrote articles for the physician newsletter, and developed a PowerPoint presentation and educational information specifically for each service line. The physician advisor provided a continuing medical education program to the medical staff as well.

The team created a "little green book" of about 80 pages that fits into a lab coat. The book includes information on the MS-DRGs, CCs, MCCs, documentation requirements, length of stays for specific diagnoses, and InterQual criteria for medical necessity, including the difference between criteria for the intensive care unit and telemetry vs. medical-surgical admissions and acute inpatient admission criteria vs. observation status criteria.

"We have 1,000 printed and handed them out at clinical service meetings and the physician expo. In addition, the case managers and the physician advisor hand them out when they interact with the physicians," Payne says.

The MS-DRG team created a library of about 30 concurrent query forms that are used by the clinical documentation specialists to query the doctors on documentation.

The majority of the forms were developed following a systemwide analysis of the hospital's most common MS-DRGs, MCCs, and CCs, and others were added based on physician interaction, Payne says.

Physicians on the hospital's utilization review committee and medical directors for the service lines had input into the development of the concurrent query forms.

The forms include definitions, such as what body mass index indicates what type of obesity, and the clinical definitions for sepsis, along with a check-off box.

They provide information for the physicians but do not coach them on what to document, Payne adds.

For instance, the heart failure form says the physician has documented that the patient has heart failure but more specific information is needed. The query form also includes clinical definitions of various types of heart failure and a check-off box. The physician simply answers the query by placing a mark in the relevant check box and signing the document.

The forms are a permanent part of the chart.

"We leave the forms in the charts in hopes that the physicians will include the information in the discharge summary so the information will be easily available in case of a recovery audit contractor [RAC] audit," Graham-Clark says.

Early on, the hospital determined that it would need additional staff to handle documentation enhancement and created the position of clinical documentation specialist, which is shared by two people.

Payne and the lead case managers handled the MS-DRG documentation program from Oct. 1 to Feb. 1, when the new clinical documentation specialists came on board.

One is an RN case manager who is in charge of clinical documentation at another hospital. The other is a foreign-trained physician with a case management background who is bilingual.

The clinical documentation specialists went through intensive training on documentation enhancement and coding and meet regularly with the coders to identify areas where they can improve.

When the clinical documentation specialists conduct daily concurrent review of the charts, they look at laboratory values, vital signs, and other clinical information in addition to physician dictation, orders, and progress notes, identifying opportunities for more specific documentation.

They query the physicians, either by using the concurrent query forms or connecting with them in person, and educate them about the documentation that is needed as well as looking for specific educational opportunities.

For instance, they worked with the emergency associates (EAs) — physicians who work as hospitalists who manage the care of unfunded patients and those without an admitting physician.

"We targeted these first because they have a contract that pays them based on the DRG payment, so accurate documentation is vital to assigning the correct DRG for their patients. Length of stay is also very important to them," Payne says.

The department tracks the physician prompt forms on a spreadsheet by type and by volume to identify educational opportunities.

Their efforts are backed by staff experts, such as the hospital's diabetic nurse practitioner who reviews the charts of diabetic patients. Their goal is to review how the patient's documentation is documented (controlled vs. uncontrolled) and to review how complications such as diabetic neuropathy are documented.

Focus on wound documentation

The wound documentation nurse also works with the clinical documentation specialist to ensure that wounds are appropriately documented.

The wound documentation process is a part of the hospital's efforts to ensure that all conditions that are present on admission are documented.

"We did an analysis to identify where there is risk for not being in compliance with the 'present-on-admission' requirements and determined that wounds are our biggest risk," Payne says.

The committee moved wound consultations to the front of the chart so they will be immediately visible when the chart is reviewed.

"The case managers check to make sure any wounds have been identified, especially if the patient is coming from a skilled nursing facility or another hospital," she says.

The emergency department case manager is a member of the clinical documentation committee team and works with the emergency department physicians and staff to make sure that all conditions that are present on admission are documented.

If nursing documents that a patient has a wound on admission, the clinical documentation specialist completes a wound-staging concurrent query form. The physician is asked to document the wound stage and signify whether it was present on admission.

Sharp Corporate Compliance works in collaboration with the clinical documentation process and participates in the monthly meetings with the clinical documentation specialists and coders to assure compliance with coding guidelines and MS-DRG documentation requirements, and to ensure that the concurrent queries do not lead or coach the physicians in their documentation.

(For more information, contact Susan Payne, RN, BSN, CPHQ, CPUM, manager, case management/social services, e-mail: