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Documentation specialists review 100% of admissions
Dedicated staff work separately from CMs
Tamara Hicks, RN, BSN, CCS, describes the work of the clinical documentation consultants as being like a detective who looks for clues and thinks ahead as to what the cause may be.
"When I conduct an initial review of the chart, I read it from the beginning, like a story — starting with the emergency department notes, through the history and physical — and start building a story from a clinical standpoint. I look at what is being described and try to determine what the documentation is not telling me," says Hicks, who is manager of care coordination at North Carolina Baptist Hospital.
For instance, if the chart indicates that the patient has an elevated potassium level, the nurse knows she needs to look for documentation of hyperkalemia.
"I'm trying to make sure that what appears to be going on from a clinical standpoint is clearly stated in the documentation," Hicks says.
Clinical documentation consultants
At North Carolina Baptist Hospital, a large teaching hospital in Winston-Salem, clinical documentation improvement is performed by BSN-prepared nurses with at least five years of clinical experience.
Called clinical documentation consultants, they review 100% of cases whether the patients are covered by Medicare, Medicaid, or commercial payers.
They review the charts of new patients within the first two business days after admission, then review them every two business days unless they have made a query to the physician and are waiting for a response or if the patient originally had no complication/comorbidity (CC) or major complication/comorbidity (MCC).
The clinical documentation consultants assign the working DRG.
"The nurses are not coding the record. They're only to say what the DRG appears to be and what are the opportunities," Hicks reports.
The care coordination department includes case managers as well as 11 clinical documentation consultants who are assigned by nursing unit.
"Clinical documentation improvement is not part of the case management role at all, and I have been very adamant to keep it separated. Case managers are already involved in utilization review, discharge planning, and throughput. Documentation improvement can't be a high priority for them," Hicks says.
Case managers and clinical documentation consultants both review the patient chart, but they're looking for different things, she asserts.
"The two groups work together, but it's a misnomer that case managers can perform documentation enhancement because they're in the record already. They're not looking for the same things. You have to wear two different hats to handle both roles, and we feel we get a lot more bang for the buck by having a dedicated clinical documentation staff," Hicks says.
The clinical documentation consultants undergo a homegrown training program that has its roots in a training video developed with the help of a consultant when the program started.
"Now that CMS no longer uses the DRG system for reimbursement, we have added to the program," Hicks says.
A supervisor works one on one with new staff members, going over the MS-DRG system and teaching them how to assign a working DRG. Then the new clinical documentation consultants shadow a peer to learn more about the system before going out on their own.
"It takes about five weeks to get a new clinical documentation specialist trained and about six months to a year for them to get proficient," Hicks explains.
Some of the nurses are specialized in a particular field and are assigned to that area of the hospital. For instance, the clinical documentation coordinator who works on the neurology and neurosurgery unit is familiar with what affects MS-DRGs and severity of illness in that population.
All of the nurses have a broad-based education in documentation that enables them to fill in for their peers on other units.
The clinical documentation coordinators make sure that the documentation is complete to demonstrate medical necessity, but they don't stop there.
"We look at the MS-DRG to see if there is potential for improvement. We need to document all the care the patient receives because it impacts our severity-of-illness data," Hicks says.
When the clinical documentation consultants have a question for a physician, they write it in the electronic medical record. They also use a computer-generated worksheet that does not go into the electronic medical record. If the physician doesn't answer the query in 24 hours, they follow up in person.
"One of the biggest challenges to this program is physician buy-in," Hicks says. About 80% of the physicians are totally cooperative, she adds.
The team educates the physicians on the importance of documentation one on one as well as in formal presentations at faculty and medical staff meetings and provides individual physicians with their query response rate.
The department tracks case mix index, revenue enhancement, CC and MCC capturing, queries and query response rate, and audits the query worksheets records for missed opportunities.
The supervisors compare the medical record with queries made by the clinical documentation consultants to make sure they are taking every opportunity to assure that the documentation is complete.
After the record is coded, the clinical documentation consultants review it a second time to see if they missed any opportunity to improve the documentation or if there is documentation that needs to be clarified.
Then either Hicks or a supervisor look at the record again to see if anything was missed.
"The goal is to make sure we are covering all the bases. The focus has shifted from just looking at the DRG to looking at severity of illness and the mortality index. Our goal is related to the hospital goal of keeping expected mortality up and the mortality index down," she says.
The hospital was undergoing an internal audit at the same time it found out the Recovery Audit Contractors were coming.
"What we learned was that even though the patient met medical criteria, the physician intent, such as admitting the patient for observation, wasn't always in the documentation. This wasn't something our utilization review nurses and case managers were focusing on. Now, when the case managers see this omission, they get it clarified or get the patient's status changed," Hicks says.