Documentation review plan ups reimbursement

Collaboration among CM, coders, physicians key

A clinical documentation review program at Jupiter (FL) Medical Center increased Medicare reimbursement by $278,000 the first year for the 156-bed community hospital.

"The crux of our success was the excellent working relationship that case management has with the medical records staff, the coders, and the physicians. If we miss something and the coders pick it up, they call us and educate us, and we in turn educate the physicians," says Cathy J. Hamilton, RN, BA, MHS, CPHQ, CPUR, director of case management.

Case managers at Jupiter Medical Center are unit-based and cover the emergency department and the intensive care unit as well as the medical, surgical, and telemetry units. A case manager is on duty in the emergency department from 6 p.m. to midnight. The case management department is piloting a physician group model on the telemetry unit.

The medical center began its clinical documentation program by contracting with William Haik, MD, director of Fort Walton Beach, FL-based DRG Review Inc., to conduct an educational session for the case management staff and medical staff on the importance of coding and appropriate documentation to reflect the severity of illness and intensity of services and its effect on reimbursement and physician profiling. The physician-directed consulting firm specializes in coding guidelines and documentation issues.

After the initial educational program, the case management department developed its clinical documentation review program and created two new positions for clinical documentation specialists, which were filled by experienced case managers.

"I wanted all the case managers to have a general understanding of documentation, but case managers have so many duties that adding something else on top of them was not feasible. I also felt that we needed staff who specialized in clinical documentation review," Hamilton says.

One of the clinical documentation specialists had been on the hospital staff for 25 years and had a longtime relationship with many of the physicians. This relationship helped when staff began querying physicians.

Preparing for the MS-DRGs

As news came out about the new MS-DRG system, the case management team started preparing the physicians for the changes in documentation they were going to have to make when the new system went into effect Oct. 1, 2007.

"We were doing really well with the program and everything changed. Now we're working on getting everybody accustomed to the requirements for the new MS-DRG system," Hamilton reports.

At first, the case management team concentrated on the 50 or so physicians who comprise the majority of admissions to the hospital and started explaining the new system.

The hospital brought Haik back in the summer of 2007 to address the changes that the Centers for Medicare & Medicaid Services had proposed and to prepare staff for the need for more detailed documentation.

"Dr. Haik educated the physicians that their documentation was going to have to change and let them know that the clinical documentation specialists would be querying them more frequently because of the new documentation requirements," Hamilton explains.

Software helps determine appropriate severity

The clinical documentation specialists use a software program that helps them identify what complications/comorbidities (CCs) and major complications/comorbidities (MCCs) the patient may have and where more documentation may be needed. They enter the patient diagnoses into the program, which asks about comorbid conditions, and then determines which MS-DRG is appropriate.

"Specificity has become more important with the new MS-DRGs. It used to be that heart failure would automatically count as a CC, but now it has to be very specific. We're not a teaching facility, so our physicians don't usually document to that degree; but we're educating them on the language they need to use," Hamilton says.

The clinical documentation specialists review the charts every day to assure that the severity of illness and intensity of services being utilized are adequately documented and for compliance with core measures. They spend their entire day on documentation review and core measures, except on the rare occasion when they are needed to fill in for another case manager.

Before beginning the documentation improvement initiative, the clinical documentation specialists reviewed the hospital's high-volume diagnoses and determined which of them were at risk for under- or overdocumentation. Then they began working with the medical staff to improve documentation. The clinical documentation specialists started out with the 20 DRGs that were the highest volume and most likely to have complications and comorbidities.

Every DRG admission reviewed

"We found that as the documentation continued to improve, we could review additional DRGs. Now we look at almost every DRG admission to the hospital," Hamilton says.

The clinical documentation specialists perform the majority of their reviews in the electronic medical record. If they need additional information, such as information in the progress notes, they can go to the floor and look at the patient charts.

When they observe a problem with the documentation, they talk to the physician on the floor or leave a written query. The case managers have a good working relationship with the physicians and their office staffs, which helps in the documentation process, Hamilton says.

"The physicians respond to us because we communicate with them concurrently, while the patient is still in the hospital. They were not responding well to post-discharge queries by the coders because the patient was already gone and they had completed that medical record and moved on. We catch them on the floor or concurrently fax information or leave messages with their office," she says.

The clinical documentation specialists frequently call on the coders with questions about documentation.

"The coding staff are the real experts. Every time we meet with them, I am amazed at the extent of their knowledge. We need their help more than ever now with the MS-DRG system," Hamilton says.

Coders, staff meet monthly

The coders meet with the case management team monthly to provide feedback and ask them questions. If the coders determine that there is a problem with the documentation when the medical records department starts working with the chart, they notify the clinical documentation specialist, who contacts the physician.

"If the coders see something that could indicate a CC or an MCC and it's not documented, it could make a huge difference in the reimbursement," Hamilton says.

If the physician typically has patients in the hospital, the clinical documentation specialist asks the case manager on the unit to call her when the physician is in the office and talks with him or her one on one. Otherwise, she faxes the query to the physician's office or calls the physician on the telephone.

Follow up with physician advisor

The case managers and clinical documentation specialists can call on their physician advisor if the physician doesn't respond to a query.

"He doesn't pressure them to give us an answer one way or another. He just asks them to give us an answer and sign the query," Hamilton says.

The case management team has worked to develop a good relationship with the office staffs of the hospital's admitting physicians. The hospital hosts a yearly open house and luncheon for the medical office staff members. The case management department sets up a display at the luncheon, with information on clinical documentation issues, utilization issues, and core measures.

"We give the office staff a list of case managers and their extensions and try to develop a good relationship with them so that when we communicate with them, they'll know who we are and make sure the physician responds to our query," she says.

Continual education

Throughout the year, the case management department continues educating the admitting physicians on the clinical documentation initiative.

Hamilton writes an article on clinical documentation for each issue of the hospital's quarterly physician newsletter.

"We try to keep the subject in front of the physicians all the time," she says.

When the hospital invited Haik to speak to the physicians at their semiannual medical staff meeting, they put him first on the agenda before the business part of the meeting.

Bringing in consultants

Bringing in a physician-directed consulting firm was an effective strategy because it was peer-to-peer communication, Hamilton says.

Haik explained to physicians how documentation can affect their physician profile and how it could affect them personally, Hamilton recalls.

"If the profile makes it appear that a physician is taking care of patients who are not severely ill and it costs a lot to treat those patients, then the insurers may not want that physician on their panel," she says. "The medical staff paid a lot of attention to Dr. Haik because he is a fellow physician."

The physicians could identify with the consultant when he told them he became involved in the coding arena because the clinical outcomes of his severely ill patients were not being accurately reflected and it affected Haik's practice profile, Hamilton says.

"He said he knew that he was a better doctor than his profile indicated. Our physicians could identify with that. Any time you can get physicians to understand how something impacts them personally, you get a lot more buy-in," she says.