Service Documentation Monthly Source: The Academy of Healthcare Revenue
Improving Clinical Documentation Through
Specialized Programs
HIM professionals nationwide have been
advised many times to improve coding by
first helping to improve clinical documentation.
Although accurate and productive
coding is a key part of attaining appropriate
reimbursement from payers, coders
cannot hope to code accurate charges if
what clinicians have documented is incorrect
or incomplete. By implementing and
participating in special programs specifically
designed to improve clinical documentation,
HIM staff can produce more
accurate codes, which will ultimately yield
more accurate reimbursements. Through
an examination of specialized improvement
programs, and the steps other facilities
have found successful, HIM departments
can identify best practices to
enhance clinical documentation and
ensure accurate reimbursement.
The aforementioned programs are
called clinical documentation improvement
or clinical documentation integrity
(CDI) programs. CDI programs and
specialists typically work to ensure coding
quality and compliance by educating
and training clinicians about proper documentation.
Methods may include clinician
shadowing, coaching or mentoring
opportunities from HIM staff to clinicians,
periodic documentation report cards, and
concurrent coding reviews.
In a recent Academy interview, one
healthcare system’s HIM leader spoke of
its CDI program. Centra Health, based
in Lynchburg, Virginia, is a regional, nonprofit
healthcare system with two acute-care
hospitals and several other healthcare
facilities. After some failed attempts
to implement CDI programs in the past,
Centra Health’s senior vice president reorganized
the revenue cycle departments. As
part of this reorganization, six HIM staff
members from both the coding and the
quality resources areas were made into a
separate department dedicated solely to
clinical coding and documentation. Centra
Health’s HIM leader, Lynne Saunders, explained why this focus on CDI was necessary:
“Clinical documentation was not as
complete and accurate as it needed it to
be,” Saunders said. “We were trying to
improve our [quality and compliance]
scores, and accurately represent the care
that we were giving. Patients were not
appearing as sick as they were because
of issues with documentation, the typical
issue that you find at most hospitals.”
Centra Health took a number of steps to
ensure that the severity of patients’ cases
was accurately reflected, and accurate
reimbursements were billed for. Saunders
outlines some of the keys below:
Defining Goals to Unify Messages. When HIM and revenue cycle leaders
decided to implement a CDI program,
they decided to engage the services of
an outside consulting firm to educate
the core CDI team. With the core team
members participating in the same
training and learning about the same
goals for the program, the message
to providers and other staff would be
clear and consistent throughout the
organization..
Obtaining Clinicians’ Buy-in. Of course, a CDI program will
not likely succeeded without the
participation and input of a hospital’s
clinicians. Centra Health took a very
interesting approach to involving its
physicians in the CDI plan. Designated
spokespersons for the program among
the CDI team visited physicians in their
offices across the region. These “lunch
and learn” sessions involved bringing
lunch to physicians, describing the
program goals and expectations, and
distributing a flyer at the end of each
lunch to physicians to summarize
what was said and have it on record to
consult when needed.
Training HIM and Clinical Staff. Staff
members participated in a two-week
training program to learn both the
details of the program and how their
duties would be affected, such as how
their tasks are completed.
Completing CDI Tasks.
Reviews of
documentation are conducted either
one-on-one or in small-group settings.
Saunders explained that the smaller
the group, the better the likelihood
that more clinicians will ask questions,
ensuring documentation is being
checked and improved. “Face-to-face documentation” is strongly encouraged
at Centra Health. The system works on
a hybrid medical record (combination
of both paper and electronic
documents), so specialists are required
to pull charts for concurrent reviews.
CDI specialists do have a special form
to complete and give to clinicians, so
they receive communication about
their performance. Additionally,
clinicians are given an opportunity
both in writing and via an automated
tool to ask questions or voice concerns.
Adequately Staffing CDI.
Saunders explained how additional staff who
specialize in CDI could be required in
some instances when she said, “In the
beginning, it was all existing internal
hospital staff. The consultant at the
time recommended that we have one
documentation specialist for every
2,000 annual Medicare discharges, so
that’s how we staffed initially. Since
then, with our addition of Blue Cross
and Medicaid, the staffing ratio is more
like one documentation specialist
for every 3,400 annual discharges for
Medicare, Medicaid, and Blue Cross.”
As Centra Health’s experience shows,
CDI programs can be very beneficial to
revenue cycle improvement efforts, with
HIM staff taking the lead in developing
and maintaining the documentation program
at their organizations. With the help
of CDI programs, healthcare facilities can
improve the accuracy and compliancy of
their documentation and, hence, their
coding, making accurate reimbursements
more possible.
The Academy of Healthcare Revenue
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Media Contact Andrea Morrill
Research Director
262-782-7919
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