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April 25, 2011

A Documentation Improvement Success Story
By Judy Sturgeon, CCS
For The Record
Vol. 23 No. 8 P. 8

Is your documentation everything it should be? Are your physicians providing all the information your coders need for accurate coding and reimbursement? Will the information be good enough when ICD-10 is implemented? Has your budget prevented you from enlisting help from a top-shelf consultant’s clinical documentation improvement (CDI) program?

There is a viable solution. Just ask the HIM department at Monroe Clinic, part of an integrated clinic-hospital organization licensed as a 100-bed hospital with an 80-provider multispecialty clinic in Monroe, Wis., and 11 community clinics in southwest Wisconsin and northwest Illinois.

Regardless of a facility’s size, several issues are crucial for all HIM departments. Monroe’s HIM department has the same needs and concerns as the largest university or national medical conglomerates: good documentation, ongoing communication with physicians, improved coding, and a positive response to a staggering number of industry changes.

Laurie Schimek, RHIT, Monroe’s HIM manager and privacy officer, says it was a whirlwind experience as the clinic attempted to take better control of its documentation practices. By addressing its needs one step at a time, Monroe has been able to keep on top of healthcare’s shifting landscape. In 2009, after converting its coding from paper documentation to a new EMR, Monroe began discussing ways to improve physician documentation in the new system.

Rather than enlist help from a vendor, Monroe felt it was imperative to create its own documentation improvement project. The reason? “We had a need to communicate. We already have the knowledge, and we know where the needs are,” Schimek says. “We identified what we did know and built on that. Then one of the inpatient coders volunteered to go talk to the hospitalists to help clear up some of the documentation questions.”

For the project to have any chance at succeeding, Schimek says gaining support throughout the clinic was critical. “We’ve been extremely fortunate in having leadership who consistently provide excellent support and have confidence in our knowledge and ability,” she says. “We quickly received buy-in from the director of information services to whom we report and from both the chief financial officer and the chief medical officer. Our initial outreach coder did her homework, too, by researching the basic concepts and needs involved in order to create an effective and compliant clinical documentation improvement program.”

The project may have seemed overwhelming, but the extensive requirements for the final product did not discourage Schimek, who recalls telling the novice CDI coder, “Let’s just look at this as an experiment. Introduce yourself; ask if there’s anything you can do to help them [physicians].”

By keeping the immediate task at hand manageable, Monroe forged ahead toward its ultimate goal.

“We don’t have any extreme extroverts here,” Schimek says. “Our first few meetings included some white-knuckle moments for our coder, but she began her first encounter by explaining the need to understand why physicians documented as they did. The coder included clinical examples of how their documentation affected the physicians’ level-of-service coding. Then she asked if they had any questions for her and once the dialogue began, there was no stopping it.”

Schimek says the idea was to create a peer relationship with the physician staff. It turned out to be beneficial for both sides, a positive experience that offered assistance to physicians as well as to the coding department. Schimek says several strategies were employed to create this cooperative effort.

“We went in to understand, not to tell them what to do,” she says. “We stopped using punitive and threatening words like ‘audit’ and ‘benchmark’ and ‘review.’ We wanted to develop an interactive relationship, so we created in their place interactive coding sessions and encouraged a peer role relationship. We made certain that our clinical examples were not identified by physician, only by the documentation issue that was of concern. We maintained an attitude of respect and we receive respect in return.”

In addition to these behavior changes, Monroe’s CDI coders created personal business cards and bumped their dress code up a notch to reflect their competence as clinical professionals. “You can’t let clothing cause you to be prejudged,” Schimek notes.

Rather than try to tackle everything at once, the CDI program focused on each department’s top five issues and required that a coder was available for 15 minutes at regular department meetings. As documentation needed clarification, coders jotted down the basic issues daily. At each meeting, the top five reoccurring items were brought to the attention of physicians and staff. As the physicians became more attentive to the most pressing problems, new ones were introduced.

Arrangements were made for a coder to participate in daily rounds, and the medical staff’s demand for her input quickly increased as more departments opted into the program. One skilled coder representative soon became several with a little time and training. Eventually, the program expanded to address outpatient clinic needs as well as inpatient concerns.

One step on a tentative path, created by need and fueled by a coder champion with little nerve and built on a foundation of good planning and cooperation, has brought significantly more to the clinic than some basic documentation improvement.

Letters of commendation from the hospitalists to the chief medical officer further validated the project’s value and gained esteem for the coders and the department as a whole. Meanwhile, case mix has improved noticeably. Trepidation surrounding recovery audit contractor audits has subsided thanks to the improvement in specific and detailed documentation. The thought of a new ICD-10 coding system and its expectations for greater documentation detail is less intimidating.

In addition to those benefits, the program has enhanced employee satisfaction, an important accomplishment in an environment where there is increased demand for competent coders. In fact, the project’s original coder champion has been promoted to coding supervisor.

“Our confidence levels have improved noticeably all around. As awareness of the knowledge and capability of the coding staff spreads even wider, their self-esteem and respectability continue to increase along with their reputation,” Schimek says.

Monroe Clinic has succeeded in turning reaction into action, initiating change rather than waiting around to find out how badly change will affect them. Their world is no longer a static environment. It’s an exciting place to work and an example to other facilities that a generous portion of ‘will do’ can become a successful story of ‘can do.’

If you’d like to learn more about the Monroe Clinic CDI program, visit www.monroeclinic.org or contact Laurie Schimek at laurie.schimek@monroeclinic.org or 608-324-2192.

— Judy Sturgeon, CCS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 21 years.