December 10 , 2007

Capturing the Right Notes
By Christina Benjamin, RHIA, CCS, CCS-P
For The Record
Vol. 19 No. 25 P. 14

Create beautiful music between coding staff and physicians by setting up a documentation improvement program.

The most radical overhaul of Medicare’s inpatient prospective payment system in more than 20 years has resulted in an increased awareness of the need for clinical documentation improvement. Under the new Medicare severity diagnosis-related groups system, many unspecified conditions that used to be classified as complications or comorbidities (CCs) are now non-CCs.

Therefore, the likelihood of obtaining optimal reimbursement for services performed at any particular hospital is directly contingent on the amount of detail the physician provides for each pathology or diagnosis. As a result, greater emphasis has been placed on the need to make the physicians aware of documenting to the highest possible level of specificity. As facilities scramble to improve their documentation, it is imperative for them to understand their options since there is no one-size-fits-all solution.

Define Change Management
Before examining possible solutions, facilities must first grasp an understanding of the term change management. The concept involves managing people and their reactions to change in a way that they will feel as supported and confident as possible while working through the challenges of learning how to adopt and function in a new environment that requires them to forsake the way things were done, gain additional knowledge, and develop different skills. We all know how it feels when we “used to know how to” do a certain process or procedure before everything was changed or new requirements were introduced.

When facilities struggle with trying to get physicians to improve their documentation habits, the physicians often suffer because they face a special set of challenges. They are expected to simultaneously work to improve the lives of their patients while staying updated on their knowledge of medicine. They must also deal with the stresses of working overtime, managing the risk of malpractice, and dealing with the challenge of increased government scrutiny. The gift of time is most precious, and therefore, they seek to conserve every moment possible.

To cope with the demands and pressures of their career, physicians often develop habits and routines that may be more deeply ingrained than we expect. Therefore, the process of change management for physicians can likely be a painful process. Not only must they work hard to unlearn their established habits and routines, they must also deal with the additional challenges of adapting to a practice that is more demanding on their time and attention.

Consider Process Improvement
To improve a process, one must first have a full understanding of how it currently works. A full understanding of the documentation workflow in your facility is crucial to determining an improvement program that would be the best fit. Identify each individual who has an input in the medical record documentation and note when and where documentation actually occurs. Create a workflow chart and discuss it with all stakeholders, especially those who document in the medical record.

Most likely, inefficiencies in this process can be identified and improvements can be implemented even at this early point. A full understanding of the process will enable staff to gain background knowledge to assist them in determining how to customize a documentation improvement plan.

Queries Are Not Enough
One traditional method for dealing with poor documentation is physician queries. Well-written queries can serve as an excellent mode of feedback and follow-up after an education session, but they may not be the most efficient way to create physician awareness regarding documentation deficiencies.

In many cases, physician queries can produce frustration for coders and physicians, as well as the chief financial officer who is looking at the rising discharged not final billed for increasing numbers of charts pending physician queries.

Queries are only a retrospective solution. What is needed is a plan that will dissolve the root of the problem: getting physicians to document all necessary detail before the documentation reaches the coder.

Show and Tell
An examination into various aspects of physician education reveals several ways in which it could be made more effective. Enhancing the content of what is presented in an educational session may make it more appealing and increase the physician’s engagement and interest. If the facility has one or two physicians who are already detail-oriented and document well and/or happen to have the respect of other physicians, they could serve as a liaison between your department and the rest of the doctors.

The liaison or physician champion could assist in training others to meet similar standards of documentation. During an educational session, this individual could share copies of selected reports to allow other physicians to better understand what is expected. The better documenters may also have additional input and ideas that they could share during the session.

Bring Out the Numbers
Just as executives and other high-level management are more easily persuaded to take action or grant approval for certain resources based on statistics, physicians also may be motivated to take action based on data. Therefore, try to incorporate facts and figures into any training program.

For instance, present an example of the amount of reimbursement that could be lost using single and multiple cases in which the deficiencies were caused by a number of physicians or over an extended period of time—or both. This may motivate physicians to change their acts as soon as possible.

Including examples of multiple physicians with documentation deficiencies may motivate the staff to collaborate to improve their documentation. Try to present it from this standpoint: “Here is what is happening, and we need your help so that we can maintain our bottom line.”

May I Have Your Attention?
When planning an educational session, consider several factors that could make it a better experience for the physicians, including the following:

• Is the presentation attractive and appealing from a physician’s perspective?

• Is it organized and concise?

• Are examples given to support the understanding of the learners involved?

• An understanding of adult learning styles and proven teaching methodologies may enhance your efforts to create an effective presentation.

• Do you engage the physicians in question-and-answer sessions throughout the presentation? Ask their input on various disease processes and treatment methodologies as you explain their coding and reimbursement aspects.

• Are there summaries presented to reinforce the material?

• Is the length of the presentation feasible? Consider having multiple short sessions as opposed to infrequent, lengthy sessions.

• If sessions are done over lunch, could you serve the physicians’ favorite foods?

Teach Me, Too!
Perhaps the physicians could speak to the coders about various pathologies (signs, symptoms, related abnormal test findings, treatment methodologies, medications, and related procedures). Especially focus on the conditions being inappropriately documented within the record and for which the coders are not recognizing the signs and symptoms and other clinical indicators for query.

This exercise would remind the doctors of the need to document, as well as make coders aware of the need to be on the lookout for those conditions. Also, check into whether your presentation to the physicians or the physician’s presentation to the coders could count for physician-level continuing education credits. If so, the doctors will have motivation to attend these get-togethers.

But How Do I Cover All the Issues?
The methodology of working with the physicians to improve their documentation cannot be a one-time thing. The best approach is to focus on a few main issues at a time. Try starting each training session with a short (five to seven questions) questionnaire. The same questionnaire could then be passed out at the end of the session to reinforce the concepts presented.

At the conclusion of the session, distribute an attractive, eye-catching card or other quick reference guide that includes a summary of the presentation’s key points. Ensure that copies are placed throughout the facility in key places where physicians dictate or document so they can use it as a reference. The color or design scheme on these cards could represent a particular theme or mnemonic that would serve as a catchword to remind everyone of the key principles.

Recruit nurses or coders to review/audit the physician documentation and have them focus on the topic(s) for that time period. They should identify documentation deficiencies and notify the physicians prior to the medical record reaching the coders. Any required physician queries following that session could include that same color or design on the reference cards to remind physicians of the theme message.

Close the Feedback Loop
As feedback is given, it could be beneficial to recognize physicians who are making improvements to their documentation. For example, a final month-end award for everyone who met or exceeded the documentation standards for that time period could be established. As a last resort, penalties or discipline can be put in place for those physicians who have not improved their documentation over a certain time period. The policy and procedure for issuing awards and discipline should be carefully thought out and documented with input from the physicians.

As new issues are identified and handled, a log should be kept of the progress being made. It should include statistics such as the number of queries over a certain period of time by subject (eg, five queries for renal failure and seven queries for congestive heart failure over the past two weeks). At each education session, the graphs or logs illustrating the progress should be shared with the physicians. Keep a diary of each implemented improvement method to measure its effectiveness. This will help determine what is and isn’t working and where changes may be needed.

Electronic Record Solutions
The suggestions mentioned thus far are primarily applicable for small hospitals that are not electronically sophisticated and do not have the resources to seek out additional personnel or consulting companies to implement a formal documentation improvement system. However, for larger facilities, engaging the assistance of a formal documentation improvement program may be a more feasible solution. And for facilities that have switched to a hybrid or totally electronic medical record system where the physicians are actually entering their documentation directly into the system, the issue of improving documentation should not be nearly as acute because the physician is typically alerted to any deficiencies in real time. Before the physician can sign off on the record, all alerts must be addressed and corrected.

A compromise may be possible if your facility has a hybrid record. In this arrangement, concurrent reviewers examine the record and send electronic queries prior to discharge. This predischarge review would be especially helpful for present on admission queries. However, the facility could still use documentation templates or other paper solutions at the same time.

Staying Compliant
Any form of education, query, or documentation improvement system should be carefully created and examined to make sure that it is not leading or otherwise noncompliant or unethical. An example of leading the physicians would be providing them only with the options that would lead to a CC or major CC. The physicians must have all options available to them so they can best describe the unique conditions for each patient. Some physicians may be sensitive in this regard. Some may request to be led without knowing what they are asking for, while others may be so suspicious of the whole process that they will balk at the least suggestion of being led.

Take care to design any documentation templates or query forms so there is no question that the physician has full authority to determine the most appropriate diagnosis. Emphasize the main goal of obtaining more detail, clarification of discrepancies, or definition of possible diagnoses based on multiple clinical indicators already documented in the record. Remember that physician education and queries should not be focused on improving reimbursement but rather to upgrade documentation as a whole.

Putting It All Together
In summary, the key to improving physician documentation is to understand the contributing factors and the primary remedies. Using your knowledge of change management concepts and the overall documentation workflow process at your facility, design your program, education, policies, and procedures to suit the needs and preferences of your physicians. Instead of pushing exasperated coders to submit more queries to frustrated physicians, consider how you can use other clinical personnel to work with the physicians to improve their documentation before it reaches the coders.

Also, consider implementing an electronic system that will prompt physicians to document details while they are in the process of recording the information for the first time. Get all your reference materials, queries, presentations, and any other information prepared for physicians approved by compliance and maintain copies of this information. Implementation of these suggestions—as appropriate for your facility—will result in happier coders, content physicians, decreased compliance risk, a lower discharged not final billed, and a healthy financial outlook.

— Christina Benjamin, RHIA, CCS, CCS-P, is an independent coding and education consultant in East Dublin, Ga., and can be reached at cmbenjamin@bellsouth.net. She works with physician champions, auditors, managers, and coders and is involved with creating or overseeing the development of tools and resources specific to the new Medicare severity diagnosis-related groups.