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Making sure the DRG is correct isn't enough
If you don't have a robust clinical documentation improvement program implemented by highly trained staff, your hospital might find itself in trouble in more ways than one.
"Clinical documentation improvement is important to ensure that the appropriate severity of illness is captured for public reporting purposes and hospital profiles, to ensure that the hospital receives the appropriate reimbursement from DRG-based payers, and to make sure that the hospital is in compliance when records are reviewed by the Medicare Recovery Audit Contractors [RACs]," says Tamara A. Hicks, RN, BSN, CCS, CCDS, ACM, manager care coordination, Wake Forest Baptist Medical Center, Winston-Salem, NC.
Clinical documentation requirements have expanded beyond the traditional boundaries of capturing the diagnosis and the correct DRG assignment. As healthcare reform rolls out and the Centers for Medicare and Medicaid Services (CMS) moves to value-based purchasing, it's going to be more important than ever for documentation to be accurate and complete, adds Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital, and partner and consultant in Case Management Concepts, a case management consulting firm based in Dallas.
"All of our measures are being looked at through public reporting now, and pay-for-performance is coming soon. We're seeing a lot of external requirements for accountability from government, and private payers are following suit. When ICD-10 takes effect in October 2013, the use of the codes will have expanded specificity with more codes available for quality and public reporting purposes, and that means the documentation has to be correct," Cunningham says.
CMS began posting hospital data for eight hospital-acquired conditions on its Hospital Compare web site on April 6. The data shows the number of times the hospital-acquired conditions occurred per 1,000 discharges of Medicare fee-for-service patients in the period between October 2008 and June 2010. Hospital-acquired conditions listed include foreign objects retained after surgery, air embolism, blood incompatibility, pressure ulcer Stages III and IV, falls and trauma, vascular catheter-associated infection, catheter associated urinary tract infection, and manifestations of poor glycemic control.
"Clinical documentation indicates severity of illness, risk of mortality, and complication rates. It drives reimbursement by affecting the hospital's case mix index, hospital-acquired conditions, and value-based purchasing," Cunningham says. "Documentation establishes expectations for length of stay, for resource consumption, and for medical necessity, and serves as a source of information for data analysis for quality and financial outcomes."
Documentation improvement measures ensure that hospitals' publicly reported measures are accurate, enhances Medicare and state regulatory compliance, and improves the hospital and physician profiles by more accurately representing the patient population. "In addition, insurers are using publicly reported measures as a way to designate centers of excellence," Cunningham points out.
Toni Cesta, RN, PhD, FAAN, senior vice president of operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and partner in Case Management Concepts, says, "Hospitals need to be paid appropriately for the services they provide, and the only way to ensure that is to make sure the documentation accurately and completely represents the patient's condition and services received. But while reimbursement is very important, public reporting is what is driving the healthcare business today. If a patient is sick and requires services, the hospital will be reimbursed appropriately if it is documented."
Cunningham says, "All of this makes it imperative for hospitals to have a comprehensive clinical documentation improvement program to ensure that the medical record accurately and completely reflects the patient's condition and services received."
Doris Imperati, MSN, MHSA, CCM, associate director of Chicago-based Navigant Consulting, has found that as she consults with hospitals about their clinical documentation program, "many hospitals have had clinical documentation programs, but they have faltered or stalled. Hospitals have got to stay on top of their clinical documentation improvement efforts and monitor the statistics each month, looking for opportunities for improvement. If the documentation isn't clear and complete, the hospital may get a denial or a reduced reimbursement and may end up with poor quality data on public reporting sites."
For example, if a patient is admitted with fever, respiratory distress, an increased white blood count, and is being treated with IV rocephin, the symptoms and treatment could be clinically indicative of pneumonia, bronchitis, a respiratory infection, or some other problem. If the physician documentation in the chart doesn't provide the exact diagnosis, the coder cannot assign an accurate diagnosis for that patient. "However, each of these conditions (pneumonia, bronchitis, respiratory infection) constitutes a different DRG with different reimbursement and length-of-stay ramifications. so it is critical for the clinical documentation specialist or coder to clarify documentation with the physician." says Imperati.
For example, if a patient's diagnosis is fever, the DRG guidelines call for a three-day stay. If it's pneumonia, the stay could be up to 5.3 days, or if the condition is defined as a respiratory infection, the length of stay could go up to 6.8 days.
Imperati says, "While most hospitals have focused their clinical documentation improvement efforts on Medicare patients, in today's healthcare environment, at a minimum they should expand the focus to Medicaid patients and those payers who reimburse by Medicare-Severity Diagnosis Related Groups [MS-DRGs]. Ideally, clinical documentation functions should encompass all payers, to improve the quality of documentation and accuracy of coding house-wide."
The responsibility for clinical documentation improvement isn't limited to just one department. Case management, health information management, quality, and compliance all have a hand in the process and should work together.
Cesta says, "A clinical documentation program should be approached as an organization-wide program, and not just the responsibility of case management and health information management. Everyone in the organization should understand that medical record compliance results in more accurate profiles for both physicians and hospitals, with more accurate portrayal of clinical complexity of patients as well as appropriate reimbursement for services provided."
Cunningham says, "All of the revenue cycle stakeholders need to understand documentation. These include case management, clinical documentation improvement, finance, health information management, coders, physicians, nursing, quality, the ancillary team, the Recover Audit Contractor [RAC] coordinator, and whoever is managing the National Coverage Decision (NCD) determination and Local Coverage Decision (LCD) determination."
Cesta suggests assembling a clinical documentation improvement team to identify trends and gaps in documentation and come up with improvement initiatives. She suggests that the team include representatives from case management, health information management, quality management, coding, and billing, along with an executive team champion, the chief financial officer, a physician champion, and a mid-level provider. The team should determine how the program will work, develop a timeline and a flow process and identify educational opportunities for all of the staff involved.
"To be successful, a clinical documentation improvement program needs an executive team champion and a physician champion who support the process along with appropriate staffing levels, and coordination and community among the documentation specialists and other departments such as quality management and health information management," Cesta says. "Develop a clear job description for your clinical documentation improvement staff, along with policies, procedures, and work flow. It's a complicated job, and the staff interfaces with so many different departments. Don't just assume your staff will know how to do it."
The clinical documentation staff should meet frequently and regularly with the coding staff so the two can work as a team. "Collaboration, collaboration, collaboration is what makes a clinical documentation program work," Cesta says.
Cesta recommends cross-training staff to a minimum level in terms of what other departments are doing and looking for. For example, the clinical documentation improvement specialists might see a deficit in the documentation that could mean the severity of illness isn't accurately reflected in the record. They can work with the case managers to obtain the additional documentation.
"When the clinical documentation improvement specialist and the case manager work in complementary fashion, it results in better documentation which allows better reviews, better compliance, and fewer denials," Cesta says.
Develop a program tracking tool that's automated, if possible, and analyze your data on a monthly basis. Establish targets. When you don't hit them, drill down to determine the reason, Cesta suggests.
Outcomes measures should include the overall, medical, and surgical case mix index and the case mix index for service lines you are focusing on, Cesta says. Include the coverage rate for specified payer groups, the physician query rate including the response rate and agreement rate, the complication rate, changes in length of stay, and the ratio of major complication/comorbidity rates (CC and MCC) for specific DRGs.
The national standard is that clinical documentation specialists review about 15 to 20 charts per day, Cesta says. Use that as a benchmark to determine how productive your staff is. Make sure they are reviewing a combination of new admissions and re-reviews, Cesta suggests.
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