Educational Report

With ICD-10 around the corner and payers both public and private backing value-based purchasing, the need for hospitals and health systems to optimize their clinical documentation and coding functions is paramount.

Elevating Organizational Performance with Improved Documentation and Coding Yet making improvements in these areas can be particularly challenging. Improvement initiatives can often be complex, depending on unified efforts across multiple departments and requiring commitment from diverse stakeholders. To take quality and financial performance to the next level, organizations need a strategy that ensures widespread buy-in and bridges common gaps between departments. With this in mind, this HFMA Educational Report, sponsored by Optum360, focuses on a collaborative approach to clinical documentation and coding that supports cross-department revenue integrity.

The Need for Change

Complete and accurate clinical documentation and coding has always been needed for payment. But pressures for greater precision are growing these days given the looming ICD-10 deadline.

“The new code set substantially expands documentation demands in scope and specificity,” notes Sandra Wolfskill, director of healthcare finance policy and revenue cycle MAP for HFMA. “Without the right level of detail to reflect the patient encounter, coders will be unable to select the right odes. Moreover, if coders are not completely comfortable using ICD-10, they may not code the claim correctly or sufficiently. The reality is that less-than-ideal performance in both these areas can significantly limit reimbursement and increase denials—a double whammy as far as payment is concerned.”

Although ICD-10 compliance is a big driver for improvement, it is not the only reason hospitals should engage in this work. Better clinical documentation can also foster revenue cycle efficiency because it reduces the need for physician queries and follow-up, streamlining the time between patient visits and claims submission. In turn, a reduction in queries curbs physician disruption, which improves satisfaction and allows doctors to focus more time on clinical care.

Thorough and accurate clinical documentation and coding can also demonstrate quality, which boosts payment in valuebased models. As a result of the recent Medicare Sustainable Growth Rate (SGR) repeal, the federal government has paved the way for more outcomes-based initiatives, including those focused on population health management. “You need specificity to effectively manage population health,” Wolfskill says. “For example, asthma has one code in ICD-9-CM, so it is very hard to differentiate someone with mild asthma from someone with a severe case, limiting the ability to target interventions. ICD-10-CM on the other hand has numerous asthma codes that more fully describe the condition’s severity. By having strong clinical documentation and coding, you can drill down into which patients have more intense conditions that require consistent monitoring, allowing you to target interventions more appropriately.”

At the same time organizations are challenged to improve clinical documentation and coding performance, many face great complexity in governance and execution of these functions. Depending on the organization, clinical documentation and coding may span many different departments, which can make improvement initiatives challenging. For instance, clinical documentation improvement (CDI) may report to the quality department while coding could be part of the health information management (HIM) department. Although revenue cycle requires complete clinical documentation and coding to submit clean claims and avoid denials, it may not share the same reporting structure or leadership as HIM or CDI. And then there are the physicians—who play an essential role in clinical documentation yet operate autonomously.

Without dynamic communication among all these groups, the potential is great for disjointed processes that underperform. When departments can’t effectively collaborate
to achieve agreed upon goals, progress will be slow to nonexistent. “These activities are like a centipede with 100 legs,” Wolfskill says. “To move forward, all the legs have to work together and go in the same direction.”

Data’s Role in Driving Performance

Performance metric data that identifies best practice targets, actual results, and variances should underpin organizational process improvement efforts, including clinical documentation and coding initiatives. By regularly reviewing defined metrics, hospitals and health systems can develop a unified perspective for assessing current functioning, identifying change opportunities, gauging the impact of initiatives, and course correcting when necessary.

A first step in fully leveraging any clinical documentation and coding improvement initiative is clearly defining the key performance indicators (KPIs) that will best illustrate current performance and future targets that support optimal revenue cycle performance. Stakeholders from all contributing departments should be involved in selecting these measures to make sure the organization gathers and analyzes the most relevant information and sufficiently tracks quality and financial impacts. Although there are many possible KPIs to consider, the following are a few critical ones to keep in mind.

Discharge not final billed. This billing efficiency indicator includes all accounts where the patient has been discharged but the account has not left the patient accounting system. Hospitals should watch discharge not final billed (DNFB) because it can point to issues with clinical documentation or coding, such as insufficient detail, elevated querying, repeat coding errors, and coder productivity slowdowns. “It is best practice to hold DNFB at three days or less,” Wolfskill says. "However, this target can vary depending on an organization’s characteristics and patient population.”

A/R days and dollars. Keeping net A/R days at less than 30 is essential for any entity trying to optimize performance. In addition to days, it is also important to check the dollars tied to outstanding accounts to get a true sense of delayed payments’ financial implications. “A high value in days or dollars means that it is taking longer than it should to accurately code accounts, get them out the door, and receive payment, pointing to improvement opportunities in coding and documentation,” says Nancy Cloutier, HIM director for Hallmark Health System in Medford, Mass. “Since cash is king right now, these are good metrics to watch. All departments associated with coding and documentation should be working together to keep these metrics relatively low and consistent.”

Denied claims. Any number of factors can cause an uptick in denials, including insufficient coding or lack of medical necessity documentation. Organizations should regularly examine their denial rate and then break it down by category.“Our HIM and patient financial services (PFS) departments review denials weekly, fixing issues as they come up and looking for patterns or spikes that could point to larger problems,” Cloutier says. “The two departments communicate informally one-on-one or via e-mail to address specific concerns. There is also a more formalized process where staff bring larger denial trends forward at the weekly meeting of the HIM, PFS, clinical, and revenue cycle departments.”

Case-mix index. This metric is based on relative weights assigned to DRGs, highlighting the acuity of an inpatient population. “As severity of patients’ illnesses increase, so does the case-mix index (CMI),” Wolfskill notes. “Hospitals should watch this measure in the context of ICD-10 to make sure they are not fundamentally altering how they represent their population, given the increased detail in the new code set. In theory, CMI will be relatively neutral pre- and post-ICD-10 implementation. However, if there is a huge shift, then the hospital should closely analyze coding efforts to verify they are accurately representing case mix.”

Coder productivity. Many hospitals are concerned about coders’ efficiency in using ICD-10, fearing major productivity slowdowns post go-live. At this point, organizations should be establishing a productivity baseline and assessing coder speed and accuracy to understand the current situation and how it may change. Hospitals should also consider tracking coder productivity working with ICD-10 by monitoring dual coding programs. Monitoring performance this way can help leaders better anticipate post go-live issues and allow the hospital to plan accordingly, possibly bringing in outsourced coders or employing new staff to mitigate potential upticks.

Number of physician queries. While the previously mentioned measures point to various outcomes that could be affected by poor clinical documentation and coding, this
metric tends to be more process focused. Organizations should expect this number to be higher just after implementing a CDI program, showing that CDI staff and coders are asking physicians for clarification on specific documentation areas. However, over time, the number of queries should drop as physicians become more accustomed to updated standards for complete documentation. Note that monitoring the difference in the number of queries pre- and post-ICD-10 can be valuable as it can illustrate how well coders and physicians are adapting to the new code set.

Query response rate and timing. This measure is useful in identifying the efficiency of the query process. In particular, it can reveal problems with the physician-CDI relationship. If the response rate is low, it may mean that physicians aren’t fully committed to CDI or it could mean they are too overwhelmed with queries to respond to each one. Likewise, if physicians are taking a long time to respond, it may indicate that the query process is tedious or not valued.

Record completeness. This HIM-focused metric indicates whether an account is ready for coding, having all required data elements: a history and physical, an operative report, a discharge summary, and so forth. “We review records daily for completeness,” says Eliana Owens, executive director for patient access and coding for Mission Health in Asheville, N.C. “If a record is missing a key element, the HIM staff reaches out to the physician to get the complete information.”

While organizations should be promptly addressing record omissions, they should also look for trends. For instance, is a particular physician consistently forgetting the discharge summary or getting it in late, requiring HIM to follow up? Are there certain patient conditions that are causing delays in getting a complete record to coding? These are the kinds of larger trends that groups can explore, seeking root causes and crafting solutions.

Clarification rate. This metric helps gauge progress of educational initiatives. Some organizations will go even more granular, tracking not only frequency of clinical conditions requiring clarification but also noting instances of changes in MS-DRG, APR-DRG, and/or severity of illness and risk of mortality. Those tracking MS-DRGs may also go even further, estimating financial impact of clarifications to use in making a financial case for clinical documentation education efforts.

FBNS. Final bill not submitted (FBNS) tracks the number of claims that have cleared the DNFB hold but have not gone to the payer and are sitting in the provider’s claims scrubber for whatever reason. “In these instances, there is usually an error that was not caught by the main patient accounting system—typically a payer-specific issue, such as a revenue code that conflicts with a CPT code,” Wolfskill says. “If not resolved, the bill could sit in the claims scrubber indefinitely, leading to a significant lost revenue opportunity.” To keep FBNS in check, the individual in charge of the claims scrubber may need to review the measure daily, verifying that claims are clearing the scrubber and fixing problems as they arise. If claims are continually sticking, then it is appropriate to conduct a rootcause analysis to uncover and resolve any underlying issues causing the delay.

Putting Data Into Collaborative Action

Although collecting and monitoring data are important activities, organizations cannot rely on information alone to elevate performance. “The truth is there is not one overarching thing that will solve documentation and coding shortfalls,” Wolfskill says. “It takes a multipronged approach that uses data to foster improved processes and communication.” The following are a few strategies for turning data into collaborative action, bringing the various components together for success.

Get leadership on board. Although garnering support from senior leaders is essential for any improvement exercise, it is especially necessary when trying to realize better clinical documentation and coding because of the multifaceted nature of these activities. “Change only happens if it comes from the top,” Wolfskill says. “The HIM department cannot single-handedly achieve improvement, nor can nursing staff. Senior leaders must insist on an interdisciplinary process for tracking, enriching, and sustaining performance. In addition to setting the stage, leaders must also allocate the necessary resources and regularly bring the cast of characters together to pursue new ideas.”

Examine governance structure. As mentioned earlier, organizations may house their coding, CDI, and revenue cycle departments in different areas. Although such a structure isn’t necessarily a problem, there are distinct advantages to bringing together all the pieces under one governance, notes Michael S. Turilli, vice president of finance for Hallmark Health System. “Having every aspect of the revenue cycle rolled under one leadership fosters heightened collaboration and communication between functions. A centralized leadership function also makes it easier to identify root causes and implement solutions, since it ensures unified strategy for making documentation and coding better.”

Create a performance improvement team. Even if the various departments aren’t all housed together, there are advantages to pulling representatives from each area to discuss opportunities. “This type of group should meet periodically to address denial trends, identify systemic issues,and spearhead change initiatives,” Turilli says. “Ultimately the group should hold people accountable, so that it’s not just making recommendations but ensuring staff takes ownership for the work.”

When looking to advance clinical documentation, it may be particularly helpful to have a multidisciplinary team guiding the process. “We have a system-wide CDI program committee in which HIM, physician champions, quality, and the revenue cycle departments meet together to talk about improvement strategies and provide guidance to physicians,” says Jean Fuller, assistant vice president of HIM for Scripps Health Corporate in San Diego. “One thing this group is doing is standardizing diagnosis definitions, so that we are consistent when a diagnosis is used and a code is assigned. The committee also has focused on standardizing the query process so that physicians and coders have a consistent experience and can glean information more quickly. This approach has allowed staff to cultivate stronger physician relationships and drive up the query response rate, which currently rests around 97 percent.”

In addition to forming a general improvement team, hospitals may want to consider creating a specific group focused on ICD-10. Made up of all the players involved in clinical documentation and coding, this group can handle issues that come up through testing, anticipate problems, and ensure the implementation goes smoothly.

Develop at-a-glance reporting. Organizations should have a defined way of sharing the KPI information they collect with all stakeholders. These reports should help leaders quickly review performance and see action areas at a glance. “Dashboards are probably the most common form of visual reporting that can communicate a variety of information to those who need it,” says Timothy O’Connor, executive vice president, CFO, and treasurer for Lahey Hospital and Medical Center in Burlington, Mass. “When developing a dashboard, you should try to create one that provides a high-level overview for executive leadership and also offers drill-down capabilities for frontline management to actively and timely address outstanding issues.”

In addition to developing an easy-to-understand format, organizations should define time frames for reviewing information. For example, a HIM director or CDI leader may want to check reports daily or weekly while senior leaders may review performance on a monthly or quarterly basis.

Provide joint training. To supplement regular meetings, hospitals can bring diverse departments together through joint training opportunities. “We are partnering with an outside firm to improve our clinical documentation, and they provide joint training to both our coders and CDI staff,” says Tracy Berry, vice president of revenue cycle for BJC HealthCare in St Louis. “Providing training this way encourages better collaboration, because it helps both departments better appreciate what each one does and the needs each has. Additionally, it has allowed us to standardize the querying process, so that everyone approaches physicians in the same way.”

Enlist a physician champion for CDI. Physician buy-in is critical to elevating clinical documentation. The more invested physicians are in the effort, the more likely they will sustain compliance over time. One way to garner support is through physician champions who leverage their peer status to help design training programs, serve as resources for their colleagues, and set the tone for improvement.

Although organizations may be concerned about finding physicians willing to serve as champions, they may be surprised at the number of takers. A good many physicians are frustrated with the current state of clinical documentation and are eager to fix issues up front, rather than maintain the status quo.

Whether the physician champion is a volunteer or hired by the hospital, this individual can serve as a vital go-between for leaders of charge capture improvement initiatives and physicians. “We employ physician liaisons who work with our HIM coders and CDI professionals to review documentation and provide information and training to our practicing providers,” says Lahey’s O’Connor. “They facilitate accurate coding, DRG assignment, and representation of severity, acuity, and risk for mortality. We believe that the physicians-to-physician interaction enhances the communication and educational experience for providers.”

Check documentation in real time. To stay responsive to improvement opportunities, hospitals increasingly are focusing on clinical documentation efforts while patients are still in the hospital to identify and correct issues before patients go home. “Concurrent review lets CDI staff serve as the first line of defense in catching documentation shortfalls that may cause coding problems,” says Mission Health’s Owens. “It also limits coder queries as well, which makes both physicians and coders happy.”

One innovative approach to real-time clinical documentation monitoring is to involve CDI staff in physician rounds. Doing so can benefit all parties because the CDI staff better appreciate documentation context while physicians gain a stronger understanding of what they have to document within their workflow.

Offer diverse physician education. Robust education is key to getting physicians ready for ICD-10 and onboard with a CDI program. To lay the groundwork for any physician training, organizations should clearly outline the benefits up front, so physicians know why they should participate and what they can expect to get out of the training. For example, while there are financial advantages to CDI, physicians will be more interested in correctly reflecting the severity of the patient’s condition and supporting quality of care. As such, when communicating to physicians about a CDI education program, leaders find most benefit when messages of increasing revenue and financial performance are secondary, acknowledging that this aspect will come automatically if clinical documentation is more exact. 

Organizations should provide training via diverse venues, including didactic presentations, practice sessions, web-based training, and so forth. Multiple opportunities such as these will allow physicians to participate where and when it is most convenient. Regardless of the delivery method, training should involve real-world examples, so that doctors can see exactly what has to change and how. “We provided 20 hours of training to our physicians, outlining the benefits of accurate and compliant documentation and how to make improvements,” says Hallmark’s Cloutier. “As a result of this effort, physicians have a better grasp of what good documentation looks like and are fully invested in the process.” 

Centralize coding. As more organizations seek to integrate business operations, some are looking to unify the coding function, whether within the organization or making use of outsourcing. “Centralized coding can be especially advantageous for large, multisite health systems,” says BJC’s Berry. “By bringing coders together, you can take advantage of size and scale. Not only can a centralized structure help with efficiency, but it can ensure more uniform alignment with best practice and faster problem identification and resolution. We can also use our quality assurance resources more effectively by sharing them across hospitals.”

Conduct frequent audits. Besides monitoring KPIs, hospitals should periodically review samples of actual clinical documentation and coding to catch any bad habits and/or check if initiatives are making a difference. As organizations begin coding in ICD-10, the need for regular and comprehensive audits becomes even more important.

Hospitals may want to pursue a combination of internal and external reviews. “While in-house audits allow you to assess documentation on a more consistent and timely
basis, they can be resource intensive,” Wolfskill says. “Plus, staff may be too close to the work and overlook things that an outside perspective might catch. An external audit can provide a more objective analysis, although the cost of such an effort may limit its frequency.” In addition, third-party audits are usually more up-to-date on any coding changes or regulatory decisions that might affect clinical documentation and coding. Regardless of what approach an organization uses, it should have a defined feedback loop to channel audit results to appropriate areas, including clinical departments, coding staff, and so forth.

Embrace technology. Technology can foster smoother and more efficient interdepartmental communication and bring processes to the next level. “Automation can quickly gather and store information as well as make it available to a wider audience at any time and in any place,” says Lahey’s O’Connor. “It allows for comparative analysis and benchmarking in an area where there is a substantial amount of data that would be hard to manage and review without automation.”

Several types of technology can support more refined clinical documentation and coding:

  • The electronic health record. The EHR is a tool that most hospitals already use, and it can be a key player in developing clinical documentation. “In our organization, HIM works collaboratively with CDI to fully leverage the EHR and improve specificity, creating forms and templates that elicit the detail needed for appropriate coding,” says Mission Health’s Owens. “By having these information-gathering tools imbedded in existing software, it makes the documentation process more organic and part of daily operations.”
  • Workflow automation tools. These technologies automatically route issues, such as lack of clinical documentation, incorrect codes, or denials, to the right department for further examination and response. “By having an automated tool, the routing process happens more efficiently and accurately,” continues Owens. “This ensures the right people are addressing problems and prevents anything from falling through the cracks.”
  • Computer-assisted coding (CAC). To offset the sheer volume of coding that ICD-10 will bring, many hospitals have invested in CAC technology. Even though this software does not code per se, it does help coders be more efficient—basically having them validate suggested codes rather than coding “from scratch.” The thought is hat by helping the coder be more proficient, the software can mitigate some of the productivity hit associated with ICD-10. Note that it takes considerable time to implement CAC system, often 8 months to a year or more. Organizations may want to phase in the technology over time, focusing on inpatient coding  first, or delay the initiative until they are more familiar with the new code set.
  • CDI technologies. These solutions are very helpful when trying to achieve greater clinical documentation accuracy and completeness. Not only do CDI technologies assist organizations in generating more complete records through physician prompts, alerts, and reminders, but they can also guide training and auditing. Particularly sophisticated software also can pinpoint the right cases to review using natural language processing and clinically based algorithms. Such technology allows users to focus on the accounts most likely to have improvement opportunities, thereby making best use of the physicians’ time and aiding CDI program effectiveness.

Maintain the chargemaster, and support cross-department systems of communication regarding updates. As an out-of-date chargemaster can lead to incorrect codes and increased edits or denials, it is important to keep track of any chargemaster changes. “We have an internal committee that meets every month to distribute regulatory changes, some of which are charge- and code-related,” says Scripps’ Fuller. “The group shares any new information with the relevant departments through a defined distribution process and requires each department to acknowledge back to the committee when they have made the change and share what the impact of any new codes will be. If the change affects another department, we are able to follow up with that group as well. We report this process to executive leaders, so they are aware we are staying abreast of any changes.” Whereas some hospitals dedicate internal staff to keeping the chargemaster current, others may not have the available resources to devote to the effort. To simplify the process, organizations may want to look to technology or third-party vendors for assistance. 

Remaining Vigilant Together

Elevating clinical documentation and coding should be a constant work in progress, requiring strong communication, data reporting, and commitment from across the organization. Ultimately, to support revenue integrity, any improvement work needs to be incorporated into daily routines, so that providing accurate and comprehensive clinical documentation and coding becomes part of business as usual. By selecting the right metrics and putting performance data into collaborative action, leaders are best able to overcome cross-department clinical documentation and coding challenges and position their organizations for success.


Our Sponsor Speaks

The Value of HIM and CDI Integration

Lorri Atkins, RN, senior director of product management, and Shely O’Laughlin, vice president of consulting, Optum360, discuss how technology enables providers to leverage CDI resources in a more sophisticated way.

Q: What role should health information management play in an organization’s CDI efforts, and how can technology help?

Health information management (HIM) operations, when conducted accurately, effectively, and collaboratively, elevate the CDI program to create efficiencies, facilitate utilization of clinical knowledge with other parts of the organization, and create a comprehensive picture—which can ultimately drive action across the organization. When synergy exists between HIM and CDI, it significantly increases the integrity of the clinical record and enables accurate decision making by the myriad parties within the provider organization who rely on the record. The improved integrity of the clinical record, making it more meaningful and efficient, translates directly to advancing both clinical and financial goals.

Technology offers the ability to prioritize and concentrate efforts on cases with a known CDI opportunity, and leverage the clinical skillset of the CDI team in a much more productive way. For instance, some technology can automate the case review process, identifying documentation requiring greater specificity and clinical classification opportunities. With a better prioritized workload, CDI specialists can focus on connecting with physicians to help them understand the queries coming to them and work to change physicians’ behavior in order to prevent similar queries in the future, paving the way to timely and proper reimbursement. Further, this prioritization frees CDI specialists to focus on other high-impact activities, such as changes related to ICD-10, value-based reimbursement, and other evolutions that will have great effect on provider organizations.

Technology today offers the opportunity to reinvent how the components of HIM and CDI interact, changing the dynamics in order to leverage resources in a much more sophisticated way.

Source: Optum360

Publication Date: Monday, June 01, 2015