Revamped documentation program raises CMI

Additional staff, training were keys to success

In just four months after the launch of an intensive compliance documentation management program (CDMP) Bon Secours St. Francis Health System's Medicare case mix index increased significantly.

"Any time we can get an improvement in the case mix index, it is significant from a reimbursement standpoint as well as correctly reporting the severity level of our patient population. This is good for the hospital as well as for the individual physicians," says James T. Jones, PhD, RN, administrative director case management and patient documentation for the Greenville, SC, health system.

The hospital redesigned its compliance documentation management program, expanding its staff by 60% and provided intensive training in documentation assurance to the CDMP nurses and medical staff before rolling out the program last September.

"The original team already was making an impact to the bottom line, but we felt like we could do better with more staff and a different model," Jones says.

Jones developed a business plan and a return-on-investment estimate and got approval to add more staff to the program and to convert one of the compliance documentation management nurses' job to a supervisory position.

Before the redesign, the compliance documentation management nurses were assigned geographically and typically covered more than one unit.

"This was really stretching them too thin. The goal was to get 75% penetration; but in reality, they had time to review only 50% to 55% of the charts," Jones says.

The compliance documentation management nurses now are assigned by service line and cover an average of about 30 beds.

"Before we redesigned the program, we had one nurse covering 50 to 60 beds. By reducing the caseload, we've increased the success of the program," he says.

The nurses are salaried and typically work Monday through Friday from 8 a.m. to 4:30 p.m. The CDMP staff do not cover weekends, but Jones anticipates that may change in the future.

The nurses all have cell phones and are available after hours if a physician has questions related to documentation.

They attend the monthly meeting of the service line medical staff and adjust their schedule accordingly.

The additional staff were hired after an extensive search to identify nurses whose background and experience matched the service line they were going to review.

Matching staff by service line

"We spent a lot of time matching the background of the nurses to the specialty they cover so they already will know what to look for and where the gaps are likely to occur. To do it any other way would be a disservice not only to the hospital, but to the nurse and the physician," Jones says.

For instance, the oncology compliance documentation manager is a nurse practitioner who no longer wanted to be in a practice setting but wanted to keep her focus on oncology.

"She is a perfect fit. The oncologists have a tremendous amount of respect for her because she is so knowledgeable about oncology. It's a tough specialty with new treatments coming along every day, and she is familiar with them," Jones says.

Before the program was launched, the nurses all completed an intensive, weeklong, 40-hour compliance documentation management "boot camp" webinar developed by a vendor. After 30 days of studying the materials from the course, they were eligible to take a four-hour certification exam, Jones says.

All of the St. Francis nurses passed the exam the first time.

"When the nurses get through with the boot camp, they have a strong working base of the MS-DRG system, how comorbidities affect coding, what the documentation should be, and what to look for when they review the charts," Jones says.

The nurses use documentation software that includes a decision tree for determining the working DRG. The physician queries are built into the hospital's electronic medical record and show up any time the physician signs into the system.

"The query is right there in front of the physician and he can answer it electronically. The process is much smoother than when we had a paper system," Jones says.

Since the new program began, the nurses' query rates have increased significantly.

As the program was rolled out, the hospital provided extensive education to the medical staff on how ensuring accurate documentation will affect them in the future.

"We've done extensive education with the medical staff in large groups, in small groups, and one on one. We met with our entire hospitalist group to explain the goal of the program and how it helps the hospital as well as the doctors. We have tremendous support from the medical staff now that they understand what we are trying to do," he says.

Most physicians don't understand that insurance companies use MedPar data to help them choose their physician panels, Jones points out.

"If physicians don't document accurately in the medical record, it may appear that their patients are not as sick as those treated by their colleagues, but they have a longer length of stay. This can affect their relationship with insurers. In addition, consumers are becoming more health care-savvy and using web sites that compare one hospital or one physician against another," he says.

The CMDP supervisor attended all the medical staff meetings in September and October and introduced the nurses who would be working with the physicians. She gave a short presentation about the program, the goals, and how it will benefit the physicians as well as the hospital.

"We pointed out that if the language isn't correct in the documentation, the case will code to a lower-paying DRG, and the hospital won't get paid for the services it provides the patient. We emphasize that this is not upcoding. We're trying to make sure that the hospital gets the most appropriate reimbursement for the care we give the patient," Jones says.

The compliance documentation management nurses attend the regular service line staff meetings and educate the physicians on their roles and how they will affect physician practices.

"The physician meetings are the perfect opportunity for the CDMP nurses to clear up any issues regarding documentation and to answer any questions the physicians may have," Jones says.

The nurses review the query list every month and identify any patterns in documentation and opportunities for improvement and discuss them at the meeting.

In addition, the CDMP supervisor has identified all the MS-DRGs that might possibly apply to each service line. During each meeting, the nurses focus on educating the physicians about documentation of three or four MS-DRGs and answer any questions.

"Over a six-month period, the nurses and physicians discuss all the DRGs relative to that specialty," he says.

Since the program began, the physicians have begun seeking out the CDMP nurses to make sure that their documentation is complete and correct, Jones says.

"The physicians don't know all the rules and regulations for coding. The purpose of this program is to coach and educate them on the proper terminology," he says.

The compliance documentation management program was born out of necessity because of Medicare and its reimbursement rules, Jones says.

"If the coders don't see specific language in the progress notes, they can't code correctly. Our nurses drill down and get very detailed in assuring that the doctors write the necessary information in the chart so it can be accurately coded," he says.

For instance, a physician may be treating a patient for pneumonia and the clinical data may support the diagnosis, but if the physician doesn't write the word "pneumonia" on the chart, the coder has to code the case as a simple upper respiratory infection, Jones says.

The initial goal of the program is to review 100% of all Medicare records and to slowly add other payers that base reimbursement on the MS-DRG system.

"We started out where we could have the most effect. Our goal is to be reviewing all payers by April 1. We want to be able to honestly say that we are reviewing all patients the same way regardless of payer source. It may not affect payment from commercial insurers, but we will feel the satisfaction of treating all patients the same," Jones says.

Jones anticipates that the education they are providing to the physicians on Medicare compliance will enable the CDMP nurses to handle all of the patients on the unit.

"The query rate should drop as a result of all the work they are doing, and we'll be able to add other payer sources without additional staff," he says.

(For more information, contact: James T. Jones, PhD, RN, administrative director, case management and patient documentation, Bon Secours St. Francis Health System, e-mail: