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Clinical documentation program keeps improving
DRG reimbursement increases more than 75%
In its second year, the clinical documentation program at Jupiter (FL) Medical Center was able to increase DRG reimbursement by 75% over the previous year.
The program generated an increase of $547,563 in fiscal year 2008 compared with the previous year, when the program increased DRG reimbursement by $313,441.
In addition to Medicare, several large commercial payers reimburse the medical center on a DRG basis.
"The whole secret to the success of our program is a close and collaborative relationship between the clinical documentation specialists and the coders, the physicians, and nurses. We recognize that they are the experts in coding and we let them know that we appreciate their knowledge and want to learn from them. We let them know that we are not trying to take their jobs but rather want to help them to have all the information they need at the point of coding," says Cathy J. Hamilton, RN, BA, MHS, CPHQ, CPUR, director of care management.
At Jupiter, clinical documentation improvement is the responsibility of two experienced RN case managers who were trained to become clinical documentation specialists. They work closely with the coders and physicians.
"The relationships they already had with the physicians was definitely an advantage for them," Hamilton says.
The clinical documentation specialists review every DRG payer medical record to assure that the severity of illness and intensity of services being utilized are adequately documented and that present on admission conditions are specified. They also monitor the record for compliance with the Core Measures.
Case managers at the 163-bed community hospital 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 11 a.m. to midnight.
Before the clinical documentation program began, the case management department started building the relationship with the hospital's coders, Hamilton says.
At the time, the coders were frustrated by difficulties in getting queries for additional information answered from physicians when they conducted their retrospective review of the patient record.
"The physicians felt that since the patient was gone and they had written the discharge summary, they were finished with the chart and had moved on. They rarely responded to the coders. In fact, their response rate was 0%. We got coder buy-in for the new program in part by helping coders on the back end by taking over the entire query process," Hamilton says.
Since the clinical documentation specialists query the physicians concurrently, the chart is almost always complete when it gets to the coders.
This makes it much easier for the coders to do their jobs and ensure that the bills get out in a timely manner, Hamilton says.
Now if the coders find something on the chart that doesn't appear to be present on admission or something that the clinical documentation specialists didn't pick up during their review, they write down the information they need and the clinical documentation specialists get the answers.
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 on the unit and talks with him one on one.
Otherwise, she places a query on the medical record and faxes the query to the physician's office or calls the physician.
100% response rate
The clinical documentation specialists have achieved a 100% response rate on their queries from physicians.
They are assisted by the physician advisor to case management who calls the physicians if they don't respond.
"They know they're going to get a call if they don't respond. We make it clear that we aren't asking them to agree with the query. We just want them to answer the query and sign the document," Hamilton says.
The clinical documentation specialists and the coders meet monthly to share information and discuss what could be improved and any trends the coders see in documentation. In between meetings, the clinical documentation specialists frequently call on the coders with questions about documentation.
When Hamilton reports on the success of the clinical documentation program, she always gives the coders credit for their role in the process.
"We include them in any celebration we have and tell them how much we appreciate them," Hamilton says.
The case managers and clinical documentation specialists educate the physicians one on one about the importance of accurate and complete documentation. The department brings in a physician documentation specialist to present a continuing medical education program to the medical staff at least every other year.
"We tell them that if they aren't documenting severity of illness of their patients, they can't accurately support a higher billing code. We stress CMS and other third-party payers are developing physician profiles, and if the profile reflects that their patients have a low severity of illness but the cost of providing service to the patient is high, they will not be sought to be on the payer's physician panel," she says.
The case management staff point out to the physicians that CMS and other third-party payers are beginning to use utilization and quality information in physician contracting and institute pay-for-performance initiatives.
(For more information, contact: Cathy J. Hamilton, RN, BA, MHS, CPHQ, CPUR, director of care management, Jupiter Medical Center; e-mail: CHamilton@jupitermed.com.)