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May 10, 2010

Document for Success
By Selena Chavis
For The Record
Vol. 22 No. 9 P. 20

In an age of tight budgets, clinical documentation improvement initiatives can help brighten sour outlooks.

Physician documentation is the foundational element to so many areas in the patient life cycle. From patient safety and outcomes to compliance and the revenue cycle, it’s the one piece that can set the stage for success or failure.

Industry professionals say getting physicians to adopt documentation best practices may be one of the greatest challenges facing today’s healthcare organizations, especially in light of an intensified focus on medication errors, present-on-admission rules, diagnosis-related groups (DRGs), recovery audit contractors (RACs), and public report cards.
“The importance cannot be overrated,” says Mel Tully, MSN, senior vice president of clinical services and education at J. A. Thomas & Associates, an Atlanta-based healthcare consulting group, who emphasizes that with the increased need for specification, it should be a no-brainer for most facilities to implement clinical documentation improvement (CDI) programs. “I cannot imagine a hospital not having a CDI [program] in today’s environment,” she says.

Darice Grzybowski, MA, RHIA, FAHIMA, president of Illinois-based HIMentors, LLC, offers an example of a typical problem and how lack of documentation lays the foundation for potential coding, patient care, and revenue cycle problems.

“Consider that a physician may document ‘blood in stool’ as a final diagnosis but doesn’t state the source from which the bleeding occurred or the cause of it,” she says. “The final coding may be then more of a symptom than the actual diagnosis, and the treatments the physician gives may not be supportive. Good documentation tells a complete story.”

Grzybowski says if the bleeding was due to hemorrhoids and the patient was sent home, it’s a very different “story” from having a physician document “probable ulcerative colitis located in the sigmoid colon as per colonoscopy, causing blood in the stools on multiple occasions for 48 hours prior to admission.” A CDI program helps educate physicians on the intracacies needed for proper documentation and prompts them on how to document conditions clearly.

And adding needed specificity to physician documentation brings tangible benefits, Tully points out, noting that in her experience, organizations see anywhere from between a 4% to 8% improvement to case mix index as well as measurable gains in public report cards and public measures of mortality, improved length of stay figures, and a stronger defense against RAC and DRG audits.

As healthcare organizations become more aware of how well-constructed CDI programs can positively impact patient care and hospital finances, there has been a groundswell of activity. “CDI has just taken on a life of its own,” notes Kathryn DeVault, RHIA, CCS, CCS-P, manager of professional practice resources at the AHIMA. “Everyone is clamoring for best practices.”

C-Level Commitment
While it’s a strategy that seems oversimplified at times, the need for top-down support for CDI cannot be overstated, according to industry experts.

“You have to start at the top and have unwavering support from your C-level suite,” Tully says, adding that programs often fail when commitment from the top falters.

DeVault agrees, noting that when programs face struggles, “if you don’t have leadership directing forward momentum, it won’t get better.”

Grzybowski points out that organizations typically have a champion who recognizes a need for improved clinical documentation. “Most times it is the HIM director, but sometimes it is the CFO [chief financial officer], revenue cycle manager, case manager, quality manager, or even medical staff leadership who recognizes a change is needed to help provide more accurate and complete documentation to support coding and reimbursement,” she says.

While many constituents may identify the need for a CDI program, there are often different motives, making it necessary to garner team support across a number of departments and disciplines. “It depends on who you talk to,” says Tully, emphasizing that at the most basic level, compliance should always be the foundation for any CDI program. “Even from a financial perspective, CFOs are starting to look at two sides of the coin—how quality and finance go hand in hand.”

Grzybowski says it takes the quality piece to make the financial component work at its optimum level. “Better quality documentation—more complete, concurrent, concise, and legible to support the coded diagnoses and procedures. This improves patient care, provides a more accurate MS [Medicare severity]-DRG assignment, assigns appropriate length of stay, and allows for external comparative data to have meaning,” she says.

Emphasis on Team Quality
After gaining C-level support, it’s important to take the time to select a top-of-the-line candidate to fill the management role.

“You need meticulous program management,” Tully says, adding that the function should reside in the quality department with strong collaboration from HIM. “It’s evolving. Years ago, it really was something that came out of HIM, and if it does now, it needs to be a collaborative effort with clinical and quality. It really has shifted with the growth of CDI.”

Grzybowski says CDI programs belong as an extension of the HIM department—which her team identifies as a best practice—vs those that try to retrain nurses in quality departments to “think like a coder.” She also sees more programs shifting to HIM-driven management vs. the old models.

“Clinical documentation improvement clearly depends on documenting in the language of coding, which isn’t always exactly how nurses or physicians are trained to think and document, so it is much more practical to teach individuals already coding certified, who have a strong clinical background and can also communicate well with coders, than train someone who does not think this way,” Grzybowski says. “Bottom line, with good collaboration and the right skills and certifications and experience, the program can succeed wherever it is managed as long as there are dedicated CDI staff positions developed.”

Tully adds that hiring the right person to handle the documentation specialist position can also go a long way toward determining the project’s success. She says to keep in mind that the way the position looks in an inpatient setting will be somewhat different from one designed for an outpatient situation.

“A lot of outpatient strategy is related to templates or the charge master,” she explains. “Inpatient is much more interactive.”

On the inpatient side, Tully says to look for professionals with strong clinical backgrounds who can interact with many disciplines, adding that when these positions are located in complex environments such as the emergency department (ED), there is a need for a more advanced clinical professional who will likely require a higher salary.

Tully says a CDI program in the ED can lay the groundwork for proper coding once a patient is admitted. “The ED is really the most important inpatient department in the hospital,” she notes, pointing out that the ED typically accounts for 50% to 70% of admissions in the average hospital. “It really forms the foundation for the inpatient stay.”

Documentation specialists assigned to the ED should focus on patient status and working specifically with ED physicians on documenting correctly for severity of illness. “Coders love these positions in the ED,” Tully says. “They realize that they have all this improved documentation which supports coding for the patient going forward.”

Don’t Ignore HIM
While the need for a strong clinical background may often lead to professionals outside of HIM, DeVault says coders have recently stepped forward to become viable options. “Coders can be strong candidates for these positions,” she notes. “I don’t think just any coder can fill a clinical documentation position, but I’m amazed at some of the coders out there who have developed and honed those clinical skills.”

Professionals suggest identifying someone with a strong clinical background who has the ability to develop collaborative relationships between coding and clinical personnel. “A key to a successful program is relationships,” DeVault says. “Without a mutual appreciation for all of the skills within the group, there can be a barrier to moving forward.”

DeVault notes that she’s seen some programs detour from CDI to improving just the DRG because there was not that essential collaboration among all parties involved. “If you document better, then your reimbursement is better,” she says, adding that it’s a natural progression. “Then there is no question from a compliance perspective about what you are doing.”

Continuous Checks and Balances
Old habits die hard and industry professionals point out that without continuous and ongoing physician and staff education and focus, the tendency for most is to fall back into old documentation patterns.

“Physicians will cooperate and maintain good habits if they know what’s in it for them,” Grzybowski says, pointing to the need for education efforts that focus on how CDI will help doctors establish more accurate profiles and less risk. “It means that they are educated properly in ongoing proper documentation concepts.”

Tully concurs, adding that one of the greatest challenges to CDI is maintaining the program’s momentum. “You have to look at how you stay engaged,” she says. “Physicians never lose their poor documentation habits without frequent interaction.”

Grzybowski divides the CDI concept into two categories: programs and projects. “CDI programs should be continuous quality improvement initiatives—documentation quality is as important as other elements of quality of care,” she says. “A CDI project should be short term and last no more than six to 12 months … and do not necessarily be repeated every year if a good infrastructure is in place.”

While it may be helpful to work with expert consultants for initial program design, education, and data benchmarking, Grzybowski has seen a tendency to rely on external consultants to do the CDI job for the staff vs. changing internal processes, which is the only way to have the long-term positive impact of encouraging and supporting quality documentation. Following up with periodic monitoring of coding audits provides the checks and balances needed from an external point of view.

Other industry insiders believe some combination of internal programs along with external consulting helps keep CDI programs healthy and forward looking. Tully suggests that a third party can provide a valuable and unbiased perspective on systems and potential pitfalls in the form of checks and balances.

“You need to have a third-party vendor actively engaged and follow up regularly,” she says.

Visibility of the program is also important in reminding clinical staff that the expectation is there for improvement. “As long as physicians see documentation specialists out and know the program is working, a program will keep momentum,” Tully says. “The minute you are not visible or interactive, they go back to what’s easiest.”

Grzybowski says one of the best ways to achieve consistent, visible, and timely communication is to implement concurrent documentation programs where mistakes are corrected while patients are still in-house and under a physician’s care rather than weeks or months later. With a concurrent documentation program in play, an audit of a patient chart the next day would reveal whether a physician had not documented enough information to capture all of the patient’s conditions upon admission.

Performance indicators and tracking mechanisms are also keys to success and keep a program in check, Tully says. “You need to look at how many reviews the documentation specialist does,” she notes. “Another important benchmark is how often they actually clarify with physicians. What is your expectation for physician response? They should answer queries 100% of the time.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.

CDI Code of Ethics
In recognition of the growth of clinical documentation improvement (CDI) and the crucial nature of the success of these programs going forward, an AHIMA workgroup has been in the process of establishing a tool kit and a code of ethics.

Available on the AHIMA Web site, the CDI tool kit offers items such as a job description, review forms, metrics for success in capturing data, tools for starting and maintaining a program, online resources, and a sample policy and procedure workup.

Currently in the AHIMA’s House of Delegates, the CDI Code of Ethics will include nine items that list ethical standards for CDI professionals. Kathryn DeVault, RHIA, CCS, CCS-P, manager of professional practice resources at the AHIMA, says the final code will go before the full House of Delegates in early June for final approval. Professionals can expect something to be available shortly thereafter.

Offering a glimpse into the effort, DeVault provided the following introductory paragraph forming the framework for the Code of Ethics: “The AHIMA Code of Ethics (available on the AHIMA web site: http://www.ahima.org/about/ethics.asp) is relevant to all AHIMA members and credentialed HIM professionals and students, regardless of their professional functions, the settings in which they work, or the populations they serve. The AHIMA Ethical Standards for Clinical Documentation Improvement Professionals are intended to assist in decision-making processes and actions, outline expectations for making ethical decisions in the workplace, and demonstrate the professionals’ commitment to integrity. They are relevant to all clinical documentation improvement professionals and those who manage the clinical documentation improvement (CDI) function, regardless of the healthcare setting in which they work, or whether they are AHIMA members or nonmembers.”

— SC

Advice: Take CDI Beyond Medicare
The most successful clinical documentation improvement programs are the ones in which the medical staff assume a leadership role. When the physicians understand the benefits of accurate and specific representation of disease processes and ask for help, you’re well on your way to pervasive success. That being the case, the strategy of going after the chief financial officer is the wrong direction to take. If your medical executive committee wants to maximize the measures of quality by the physician membership for all service lines, it can make the CEO do what’s best for the hospital.

If you limit your program to Medicare, you’re not helping the medical staff. Imagine what the pediatricians and obstetricians and neonatologists think of your program when they are excluded from the opportunity to do better because they don’t deal with diagnosis-related group (DRG) payers. And the measures of success extend way beyond case mix index and the effects on DRG assignments. With the impetus already started by insurance companies to recognize utilization related to severity-of-illness measures, you have to do what’s right—extend your program to all payers, patients, and physicians.

Will you see financial benefit? Almost absolutely. But if you ignore non-DRG payers, you’ll have no chance to get to the point that medicine has been moving for the past five years or so, and that’s recognizing the physicians, groups, hospitals, and hospital systems that the insurers can sell to their membership. They will negotiate better rates to the folks they can sell and reduce rates to the folks who are desperate for money.

It’s the profiles that lead reimbursement, not the DRG assignments. It’s the value for the dollar—internists and surgeons alike—that will lead the way to the future.

— Robert S. Gold, MD, is CEO of DCBA, Inc.