Documentation initiative pays off for hospitals

Care managers perform intensive concurrent review

Since Hurley Medical Center in Flint, MI, began a comprehensive program to improve documentation, reimbursement has improved and the hospital’s severity of illness and risk of mortality data have come in line with benchmark data.

"Before we started this initiative, when we compared our case mix index to benchmarks, it appeared that the patients at our hospital were not as sick as other patients but they had a higher risk of mortality and longer lengths of stay," recalls Teresa Bourque, RN, BSN, senior nurse care manager the medical center.

Hurley Medical Center is a Level 1 trauma center with a high-risk birthing center and a neonatal intensive care unit. It serves a large indigent population.

"It didn’t seem right that our severity of illness and risk of mortality were off the mark for our lengths of stay," Bourque says.

The hospital hired an outside vendor, 3M Health Information Systems, based in Salt Lake City, to assess what was needed to improve clinical documentation, to train physicians, nurses, nurse care managers, coders, and utilization management coordinators and to provide software to manage health care data.

"We use the information we learned in class to help with our mission of better documentation, decreasing the lengths of stay, and making sure the patients can be safely discharged," Bourque says.

The initiative went live January 2003.

Before the new program, when care managers or utilization coordinators reviewed the records, they were looking for severity of illness to indicate that the patients met the criteria to be in the hospital.

"Now we look more thoroughly at the patient records — not just the progress notes but the anesthesia records, intraoperative notes, the nursing notes, laboratory results," Bourque says.

The care managers conduct a concurrent review of records looking for clues that might indicate a problem area in coding. The goal is to review patient charts within one day after admission.

"The purpose isn’t just to improve revenue. We want to document that our patients are really sick and to make sure their conditions are properly documented," she says.

The inclusive picture of the patients

This initiative has expanded the nurse care manager role in looking at the inclusive picture of the patient, Bourque says.

For instance, they are looking at radiology reports — not just at admission but those that come in during the stay. They look at laboratory results, comparing those when the patients were admitted to later results.

"We find instances when the patient’s labs looked fine when they came in. Later on, the results show that their protein level is going down because they’re not eating sufficiently. This may perhaps suggest malnutrition as a complicating process. Then we know it’s time for a nutrition consult," she says.

The care managers examined the diagnosis-related groups (DRG) in which Hurley’s patients’ lengths of stay exceeded the benchmark lengths of stay and scrutinized the records to see why.

Here are some of their findings:

Chest pain.

The care managers found a number of patients who were being admitted to the hospital with a diagnosis of chest pain when they actually had coronary disease.

"We make sure there is proper documentation of the underlying condition. In these instances, the chest pain may be more accurately related to anginas opposed to nonspecific chest pain," she says.

Trauma cases.

The care managers focused on trauma cases to see if patients with significant trauma were in the correct DRG.

"If they have multiple trauma, that puts them in a higher-weighted DRG, but often it didn’t indicate that in the chart," Bourque says.

Neonatal care.

According to benchmarks from the Centers for Medicare & Medicaid Services (CMS) some patients in Hurley’s neonatal unit were coded in a DRG that indicates a four-day stay but were staying seven or eight days.

"We closely scrutinized the records and determined that the documentation supported that these patients should be in a different DRG. When the patients were coded correctly, our DRG was not off-base compared to the benchmarks," Bourque adds.

Sepsis secondary to a urinary tract infection.

Some patients with severe urinary tract infections were in the intensive care unit because they were in septic shock, but their charts were coded to indicate simply a urinary tract infection.

"Patients aren’t admitted with urinary tract infections. These patients were on IV antibiotics. This is another example where the proper documentation is important," Bourque says.

The care managers and coders meet monthly to discuss some of the cases, look for patterns in which the incorrect DRGs are coded, and come up with ways to improve the documentation.

For instance, there was a problem with coding guidelines for exploratory laparoscopy followed by surgery or other procedures. Sometimes the physicians were using only the exploratory laparoscopy coding instead of the procedure coding.

The coders presented the information to the care managers, who took it to the physicians.

"We are looking at the data we get on our DRGs and comparing them with our lengths of stays. We use the data to see if we need to address outliers whose lengths of stay are longer than average or if they are really sick patients who need to be here," she added.

The purpose is to make sure clinical resource utilization is properly documented to allow assignment of patients to the appropriate DRG, Bourque points out.

Because the care managers were spending more time with the charts and less with the patients, they called on the hospital social workers to pick up some of the patient time and depend on nursing to alert them when a patient’s needs call for more intensive care management.

The hospital revised the admission assessment to include triggers for care management on patient needs.

"The care managers initially felt they didn’t know their patients as well. We have found that it helps with the documentation piece to go into the room, talk with the patients, and find out what’s going on," she says.

For instance, if the care manager visits a patient and notices that the patient isn’t eating, he or she can alert the physician.

Hurley’s care managers work more closely with physicians under the new system. "We aren’t just looking at patients’ discharge needs but also documentation and the patient record."

When the nurse care managers finds something in the chart that is not clear, they ask the physician for clarification. Most of the queries to physicians are written and placed into the progress note section of the chart. They are not a permanent part of the chart. Sometimes the care managers make a verbal inquiry about documentation to the physicians and encourage appropriate documentation of the clarification in the medical record.

For instance, the patient might be prescribed albuterol and an inhaler, but there isn’t documentation of a diagnosis that is associated with those treatments.

"When we speak with the physicians, we suggest several DRGs that maybe the patients should be assigned to with the various assigned weights. We meet with the physicians to see if there is something they are seeing about the patient but are not writing in the chart. We work with them to get the patient into the appropriate DRG based on the proper documentation of clinical resource utilization," she says.

The hospital’s chief of staff and vice president of medical affairs are involved in the process and can approach physicians to discuss individual issues.

Bourque goes to the medical staff meetings and presents her findings to the physicians.

The queries that care managers send to physicians about documentation are phrased so they can be answered "yes" or "no." "At last report, 98% of the questions the physicians answered were answered with a yes’ with regard to proper DRG assignment," she says.

The physician response to the documentation questions has been less than 50%. The goal is to get up to a 75% response.

The software used by Hurley Medical Center to track documentation and DRG assignment contains a worksheet documenting the questions sent to physicians. The care management department conducts reviews to determine how many care managers are asking questions and how many physicians are responding to the questions.

"We can break out data by physician and by care manager and determine if the physician responded by coding along the lines the care manager was thinking of or if they went in a totally different way. We make sure the clinical documentation supports the coding," she says.

Every three months, the 3M consultants do a data review follow-up with the medical center based on the information they get from the weekly reports of coding.

"They get the reports on a weekly basis just as we do. We pull certain diagnoses and review the record to makes sure the coding is on target and ensure there are no missed opportunities," she says.

If there are areas that need improvement, 3M provides benchmarking based on other hospitals.

"It’s a very good program. It’s very thorough, and it gives the care managers an opportunity to see the revenue side of the hospital. This is particularly important with patients who have a long length of stay. If a patient is very sick, you want to make sure there is correct documentation to support proper reimbursement for the services they get while they’re here. If they are going to have an extended stay, we should get paid for it, and the only way to do that is to document properly," she says.