by JoAnne R. Hahey and Mel Tully
At a Glance
Pittsburgh’s Jefferson Regional Medical Center took the following steps to improve the accuracy of its clinical documentation:
- Convinced staff of the need to improve accuracy
- Educated staff and physicians
- Communicated responsibility and accountability
- Tracked and benchmarked key data
Hospitals are in their first year of transition to the Medicare severity-adjusted diagnosis-related group (MS-DRG) system, adapting to a Centers for Medicare and Medicaid Services (CMS) recalibration that introduced new or modified DRGs to improve the recognition of severity of illness as a more accurate method to explain patient condition and differences in cost.
Realizing the potential impact on the case mix index (CMI), some hospitals are working to dramatically improve clinical documentation, allowing for the highest possible specificity in coding. Yet, as many in management are discovering, having hospital staff concurrently review clinical documentation for completeness for improved reimbursement takes more than training. Concrete changes in how people work, the process needed to better describe a patient’s condition, and the way staff interact with each other and with technology to identify comorbid and secondary diagnoses are required.
Jefferson Regional Medical Center, a 376-plus-bed community healthcare provider located in Pittsburgh, embarked on improving its clinical documentation process several years ago, realizing that more accurate documentation and coding would not only improve CMI, but also positively affect its quality core measures and profiling.
“The State of Pennsylvania through the Pennsylvania Health Care Cost Containment Council has been very aggressive in posting and tracking patient outcome results such as mortality, readmission, and length-of-stay data, as well as hospital charges,” says James A. Hoover, vice president of quality at JRMC. “Before the DRG shift came to light, we were already committed to improving quality scores, improving patient safety, and helping our doctors prepare for the move to profiling--and more accurate clinical documentation is where it’s at.”
First Hurdle: Convincing Staff
In October 2006, Ronald Boron, MD, then vice president of medical affairs, became increasingly convinced that improved clinical documentation was critical to improving quality and increasing reimbursement. He attended coding sessions, quickly understanding that coding is key to accurate reporting, fair measurement, and hospital and provider profiling.
After reviewing several clinical documentation programs and visiting several hospitals, Boron recommended that JRMC adopt a documentation management program with a core measure/quality module and begin an aggressive program to retrain and educate staff on why and how documentation would need to change. Viewed as the physician champion, Boron also met one-on-one with medical staff, convincing them that it was in their and the hospital’s best interests to be recognized and reimbursed for the care they provide.
Coders came to understand the significant difference between accurate coding versus accurate documentation. Before the switch to the document management program, when finishing up a case, coders might realize that possibly another complication or comorbidity (CC) had not been accounted for and would circulate the chart internally to get input or even query a physician, if necessary. “We were coding correctly before we implemented [the program], but our process in place to capture comorbid or CCs for improved reimbursement was done retrospectively, after discharge. We needed a way to capture these documentation opportunities while the patient was still in-house,” says Mary Mylo, director of performance improvement.
Although there was skepticism at first--by physicians and by those who questioned an up-front investment--it became clear that JRMC would benefit from a focus on the most accurate and complete documentation of its healthcare delivery.
Educating Staff and Physicians
The first step was to put in place an educational program and a multidisciplinary, team-based committee that would ensure smooth, regular communications between coders and medical staff. It was decided that the new role of clinical documentation specialist (CDS) would best be filled by a registered nurse with a strong critical care or medical/surgical background. The CDS would be charged with concurrent documentation investigation, reviewing and re-reviewing the record while the patient is still in the hospital, and working with the physician to achieve detailed documentation during the patient stay.
As with any newly recreated position, the possibility existed that there could be animosity or resentment, but JRMC created an open and team-based environment. “Once we hired three full-time, dedicated CDS positions, we also wanted to ensure that the new CDS staff could work comfortably and honestly with coders and vice versa. We set up biweekly meetings where coders and CDSs would sit down and go through cases, discussing difficult charts and coding decisions. But to be successful and move the process forward, we needed to respect each others’ opinions, and fortunately, we did just that,” says Mylo.
The second step was physician education, arguably the most important and challenging aspect of changing the mind-set and routines related to clinical documentation improvement. At quarterly medical staff meetings, physicians were educated as to the documentation impact on profiling and compliance, and were provided with specific clinical examples of what was needed to change. From the very beginning, the goal has been to ensure that practicing physicians are actively involved in ensuring the accuracy of measured and reported data.
“We had to make doctors comfortable with how CMS wanted treatments and clinical conditions documented, although from the doctors’ perspective, it won’t change how they treat patients clinically,” says Rachele Schulz, director of medical records administration at JRMC.
For example, according to Schulz, prior to the transition to MS-DRGs, congestive heart failure (CHF) was automatically considered a comorbid condition. But an unspecified CHF is not a CC or major complication or comorbidity (MCC), which doesn’t improve reimbursement. “So, at this point, we need the physician to document if it is an acute or nonacute case, or systolic or diastolic to help us code it as a CC or MCC. Again, this doesn’t change how they treat the patient, but it’s critical for our CMI and also their profile.”
It was also important to remind physicians that their commitment to improved documentation was worth their while. With an increase in physician profiling, physicians would have a stake in ensuring that documentation accurately reflected the severity of their cases.
The documentation management program set out an established process for coding records. This included completing worksheets and communicating with the CDS, as necessary, to clarify any documentation, in addition to attending task force meetings and coding clinics.
Through training, coding professionals were given additional tools and prompts to identify opportunities for documentation improvement and were empowered to issue a physician query, asking the staff physician to clarify and more fully complete any documentation.
Also, clinical documentation software helps point a CDS in the right direction for each case he or she reviews. For example, the CDS might input a congestive heart failure (CHF) diagnosis based on what the physician says. The software then will show the possibilities for increasing severity of illness and the corresponding DRG--for example, is this a case of an acute systolic CHF? This prompt presents the CDS with an opportunity to query the physician, if approved.
Communicating Responsibility
At the heart of the documentation improvement program was the JRMC steering committee, including the vice president of medical affairs, COO, CFO, vice president of quality, director of performance improvement, director of medical records administration, and a physician adviser. Collectively, they are responsible for ensuring that the program stays on track and continually improves, and that staff are kept informed and held responsible for achieving goals.
For physicians, active and committed participation in improving documentation is measured based on their response rate to physician queries. “We track physician response rates, irrespective of whether they agree or disagree with a CDS query,” says Mylo. “If physicians respond more than 75 percent of the time, they get a green light; 60-74 percent, they get a yellow light, and 59 percent or less, then it’s a red light.”
The steering committee decides on an individual basis how best to approach and work with the “red light” physicians. JRMC relies on a physician adviser to navigate sensitive situations. The physician adviser can meet with medical staff and discuss why and how physicians can improve their response rate. In some cases, a “green light” physician was asked to speak with colleagues and help educate them as to why responses are important.
Staff are also informed and educated through messages posted in lounges and staff newsletters that include updates on the documentation improvement program. “The real focus is now on continuing education of the physicians. We keep coming to them, explaining what we need and expect; with repetition comes understanding,” says Hoover.
Tracking and Benchmarking
In August 2007, the steering committee began receiving monthly reports monitoring key data to show improvement in clinical documentation. Several key reports are used to gauge progress and continually improve the program.
First, overall case reports track the following:
- Clinical documentation reviews of the total Medicare discharge population
- Interaction and querying between clinician and physician as well as coder and physician
- Top-volume DRGs and how those numbers are shifting
- CMI against the baseline (1.48) and change in CMI since the clinical documentation program was implemented
Second, the steering committee looks at DRG proportions even more specifically to determine areas for documentation improvement and further education.
Third, expanded reports delve even deeper into subject areas, comparing JRMC’s progress with a baseline or its peer group. These reports include a look at CMI, total MCC and CC capture rate, and surgical and medical MCC and CC capture rates.
Results
What have the progress reports told us? Within three months of initiating the clinical documentation program, 91 percent of Medicare cases were reviewed for compliant and complete documentation. Physicians have responded to queries 84 percent of the time and concurred with 90 percent of the queries. These queries are for MCC/CC and principal diagnosis clarification.
Coding with a CC or MCC shows increased severity of illness, increased resource consumption, and expected longer length of stay.
Before using the program to improve clinical documentation and adjust to the new MS-DRG system, JRMC’s CMI was 1.48 for FY07. From October 2007 to Jan. 21, 2008, its CMI increased to 1.639, despite the DRG shift. Other notable successes include:
- For DRG triplets,* JRMC is achieving a 42 percent MCC capture rate--which means it is successfully capturing the highest severity of illness.
- Surgical CMI impact is achieving a 3.25 overall CMI.
- Medical CMI impact is achieving a 1.12 overall CMI.
- With medical secondary diagnosis triplets, where severity of illness is further scrutinized by looking at the MCC capture rate within the medical population, JRMC is reaching a 41 percent MCC capture rate--which is even more impressive, because medical secondary MCC diagnoses are much more difficult to document severity of illness.
Beyond Reimbursement
Quality, profitability, and profiling are three compelling drivers for our documentation improvement process, which is viewed as a long-term, continual effort to strive for the highest level of accuracy and a complete medical record.
The keys include starting the program off on the right foot, such as hiring a trusted physician adviser and CDSs with good people skills; making sure our documentation process is concurrent, not retrospective; adding in a quality/core measures component; ensuring we capture severity of illness; and getting the right tracking reports to make adjustments and establish a continuous improvement process.
Footnote:
* Base DRGs are now subdivided into severity subgroups with two to three different levels of CC severity, with MCCs capturing the highest clinical severity and, as a result, the most appropriate case mix. The “triplet” group of DRGs includes DRG with major CC (MCC), DRG with CC, and DRG without MCC or CC.
JoAnne R. Hahey, CPA, is vice president and CFO, Jefferson Regional Medical Center, Pittsburgh, and a member of HFMA’s Western Pennsylvania Chapter (joanne.hahey@jeffersonregional.com).
Mel Tully is senior vice president of clinical services and education, J.A. Thomas & Associates, Smyrna, Ga. (mel.tully@jathomas.com)