Constant analysis helps improvement team succeed

Nurses, coders work together to assure accuracy

At DCH Health System, the clinical documentation improvement team takes a proactive approach to changes in the Centers for Medicare & Medicaid Services (CMS) documentation requirements.

For instance, as soon as the current MS-DRG system was proposed, the team began educating the physicians on complete and accurate documentation for congestive heart failure months before CMS began requiring specific documentation for the condition to be documented as a complication/comorbidity (CC) or major complication/comorbidity (MCC).

"It takes a good three to four months for physicians to routinely start following the new documentation requirements," says Robin Holmes, RN, MSN, manager of clinical documentation improvement at DCH Regional Medical Center and DCH Northport Medical Center in Tuscaloosa, AL.

The team started learning the APR-DRG system in 2006 when CMS proposed switching the DRG reimbursement system to the APR-DRG system developed by 3M.

Now, in addition to using the MS-DRG system for coding, the hospital's clinical documentation improvement department tracks the hospital data using the APR-DRG system to get an idea of how the physicians and the hospital system will stand up to national benchmarks, Holmes says.

The all-patient refined DRG (APR-DRG) system is more severity adjusted than the MS-DRG system, she adds.

"We know the APR-DRG severity level is close to the severity level used with public reporting. We can look at how we come out on the APR-DRGs and look for opportunities for improvement," she says.

The APR-DRG system ties severity of illness and risk of mortality to every DRG, she says.

Holmes works closely with the coding manager who prints out the hospital's case mix index every month and distributes it to everyone on the clinical documentation improvement team.

The clinical documentation specialists are all aware of the case mix index and, if it changes, they drill down to find out why.

"If it's up, it's usually because we had a high number of surgeries. If it's down, we look at whether the CC capture rate was down or it was due to another factor, such as fewer surgical procedures than usual," Holmes explains.

"We are always looking for opportunities to improve the quality of documentation and coding," she adds.

The team also tracks the hospital's symptom rate, or how many charts were coded with a symptom as the principal diagnosis.

"We don't want a chart to be documented with just a symptom and not a diagnosis. A lot of times, the physician knows what was wrong with the patient and just didn't document it," Holmes says.

The hospital system began its clinical documentation improvement program in 2002 when the performance improvement department targeted key DRGs for a pilot project to improve documentation.

The project was so successful that the hospital system decided to launch it in its two largest hospitals with dedicated staff who reviewed the charts of all Medicare patients for documentation integrity, Holmes says.

The clinical documentation specialists are nurses who go through a six-week training period developed by the hospital system and continuing education provided by the state quality improvement organization (QIO).

The clinical documentation specialists rotate weekly through the service lines in the hospital and prefer the rotation because they can keep up their skills in all areas, Holmes says.

"We tried having them unit-based, but it works best if they can rotate. Because we offer weekend service, it's good for all the clinical documentation specialists to be familiar with documentation for all of the MS-DRGs. If someone is assigned to the cardiac unit and they have to review a neurological case on the weekend, it would be difficult," she says.

When the program started, the team began a post-discharge review initiative at the end of the month, after the bills had dropped. Each team member was assigned a particular DRG to review. He or she pulled all of the records and looked for opportunities to improve the documentation.

"Many coded charts have an educational opportunity for the clinical documentation improvement team, coders, and physicians," Holmes reports.

For instance, the team has targeted charts of patients with the diagnosis of chest pain. Here's one scenario: The physician does a cardiac work-up that is negative and writes discharge instructions for lansoprazole and to follow up with a gastroenterologist. The patient has a history of gastroesophageal reflux disease.

"This is an opportunity to follow up with that physician and discuss with him that, if after study, he suspects or has determined the etiology of the chest pain, to please document this in the medical record. We can explain to the physicians how this might affect their physician profile and they are usually attentive," Holmes says.

By studying the charts, the team found items that were documented that the coder had missed and details that the clinical documentation specialists didn't get a chance to clarify while the patient still was in the hospital.

"We quickly recognized the need for a clinical review of coded charts prior to billing. As part of a team effort, the clinical documentation improvement specialists, corporate compliance, and medical records developed a system that would combine the clinical knowledge of the clinical documentation improvement team with the coders' knowledge of coding guidelines to assure that the charts are coded in a complete and compliant manner," Holmes says.

Currently, the team reviews the charts of all Medicare patients prior to billing.

"The clinical documentation specialists and coders work as a team to make sure we have an appropriate principal diagnosis and that every opportunity for accurate documentation has been satisfied," Holmes adds.