Implementing a Clinical Documentation Improvement Program

Vol. 13 •Issue 17 • Page 25
Implementing a Clinical Documentation Improvement Program

There is a strong emphasis today in the health care arena on compliance and staying on the right side of the law when conducting business with the federal and state governments. Mention the terms “compliance” and “fraud and abuse” and the topic of medical records coding and billing comes to mind in most health care professionals’ minds. Factor in the provider’s fear of monumental fines paid by health care organizations for engaging in what is perceived to be fraudulent, noncompliant billing practices with continually decreasing reimbursement for providers from the Medicare and financially strapped Medicaid programs and suddenly there is heightened acuity of the importance of thorough medical record clinical documentation.

This increased interest in securing complete and accurate medical record documentation extends to all facets of health care services, including inpatient and outpatient encounters as well as ancillary services. Thorough and complete medical record documentation is of material benefit to the health care facility as well as the physician, not to mention patient continuity of care. Medical record documentation serves as the basis for coding and billing from the patient and facility side, contributes to representation of the severity of illness and intensity of service of the patient served, and supports medical necessity and justification for patient services provided.

The Advent of Documentation Improvement Programs

Recognizing a service niche, health care consulting practices are astute at developing and marketing a product or service to meet the need. Witness the growth of different product/service offerings currently being billed as clinical documentation improvement programs by various health care consulting firms. Each has a unique name and all aim to “improve clinical documentation” for purposes of ensuring conformance to established coding guidelines and regulations. At the same time, they advertise they will help in securing all the reimbursement the hos-pital is entitled to, taking into account the services provided and health care resources consumed in managing the patient.

The methodology and processes employed in the delivery of the service are virtually the same, aside from a little variation. In general, the hospital hires several clinical documentation specialists, usually nurses, to be trained by the health care consulting firm in proper techniques of medical record documentation. The training programs generally consist of instructing the clinical documentation specialists or case managers in DRG methodology; rules of coding including determining the principal and secondary diagnoses; recognition and identification of complication and co-morbid conditions; and variations in disease processes such as sepsis vs. urinary tract infection, simple vs. complex pneumonia, respiratory failure vs. COPD exacerbation; renal failure vs. renal insufficiency; and acute blood loss anemia vs. unspecified anemia. The length of the training varies ranging from four to six weeks of combined classroom and “on-the-floor” training. During this time period, the use of clinical prompters and “query forms” are introduced to the clinical documentation specialists. These tools are designed to prompt the physicians to document certain diagnoses when clinically appropriate, given the patient’s clinical presentation and management while hospitalized.

While These Programs Are Becoming Popular

There are certain salient points that need to be considered when contemplating implementation of a clinical documentation improvement program. Each of these points must be thoroughly analyzed. The degree of relevance must be considered and specifically incorporated into the final contract with well-defined language. Areas to consider and questions to ask include:

•Extent and content of the clinical documentation specialist training.

•Is the documentation improvement program “off-the-shelf” or will it be tailored to the needs of the facility?

•Will they perform a benchmark analysis and assessment of the hospital’s current clinical documentation and medical records coding? Or will they pull data from Medpar and sell variance from that?

•Are measurable milestones of the program identified and clearly spelled out in the contract, with timetables for achievement?

•Is the program truly physician driven, geared toward physicians for the benefit of physicians and the hospital or is it more geared toward revenue enhancement?

•How are measurement, quantification and qualification of the success of the clinical documentation improvement program accomplished?

•Are the medical records coders included in the training program and if so, to what extent?

•Does the clinical documentation improvement program incorporate elements of clinical knowledge base training and medical necessity or is it strictly focused upon the acquisition of “buzz” words?

The importance and need to consider these questions and points before committing to a specific health care consulting firm’s clinical documentation im-provement program cannot be stressed enough. The intermediate and long-term success of the program hinges on addressing the above issues in an affirmative manner. Hospitals that assertively indicate their vision and expectations of a clinical documentation improvement program have met with measurably greater success than those who settle for a “canned-off-the-shelf” program.

Is There a “Best” Model?

Clinical documentation improvement programs that have consistently achieved long-lasting success take a slightly different approach to the program. While all programs engage clinical documentation specialists as a change agent in the clinical documentation process, models that capitalize upon a physician’s clinical expertise, knowledge and rapport with the medical staff have met with much greater success in facilitating improvement in overall physician medical record documentation patterns. What I mean by “capitalizing upon” is the physician actually reviewing inpatient records concurrently, identifying instances where present medical record documentation requires clarification or increased specificity to appropriately reflect the patient’s clinical conditions, severity of illness and overall physician medical management.

Physician-to-physician communication and interaction is found to be the most effective in terms of providing physician documentation education and effecting meaningful behavior modification change in the clinical documentation process that stands the test of time. It is this physician-to-physician interaction that best serves to reinforce the rationale and importance of accurate, concise and specific medical record documentation.

The physician’s efforts in the change process can be supplemented by the clinical documentation specialist’s responsibilities and duties in reviewing records concurrently and working with the medical records coder to increase their clinical knowledge base, skill sets and core competencies, a necessity in interpreting record documentation and accurately assign ICD-9 and CPT codes.

The End Result

To this end, there is a “true” team approach in implementing a clinical documentation improvement program. The end result is a well-balanced program that brings the essential parties to the table with the same goals and objectives in improving medical record clinical documentation. Clinical documentation improvement is the true focus as opposed to obtaining key “buzzwords” to enhance reimbursement to the hospital. Each party is working in tandem to achieve the same outcome and results rather than focusing upon the level of congruency between the clinical documentation specialist’s DRG with that of the medical records coder’s for the same case.

The merits of embarking on a clinical documentation improvement program cannot be argued against and underscored. The manner in which the clinical documentation improvement program is structured, reflecting the individual needs of the hospital embarking on the documentation initiative, and ultimately implemented, will form the basis for the short- and long-term success of the documentation program. Individual hospital experience over time has emphatically demonstrated that clinical documentation improvement programs that promise quick results with short-term investments in terms of time and resources do not provide long lasting impact for the hospital.

Glenn Krauss is vice president of coding compliance with DCBA Inc. He has more than 11 years of experience in the HIM industry as a practicing coder and consultant in DRGs, ICD-9 and CPT coding, APCs and billing.