UMHS Clinical Documentation Improvement Program Impacts Bottom Line
Revamping documentation process promotes efficiency, quality and improves payments to institution
When hospitals treat Medicare patients, they must file documentation to be paid for the services they provide. If documentation is incomplete or inaccurate, the result – for hospitals and patients alike – is costly. In 2005, the University of Michigan Health System underwent several changes in our clinical documentation processes that are improving patient care – and payments to the institution.
Background
To receive payment from Medicare, hospitals must submit documentation using approximately 500 Diagnosis-Related Group codes that describe various medical conditions. The more detailed the diagnosis (through the DRG codes), the more likely the hospital will be paid properly for all services provided.
As a major academic health care institution, UMHS treats a large number of Medicare patients – and often patients whose conditions are more severe and complex than those in other hospitals. Improperly documented diagnoses can result in the loss of hundreds of thousands of dollars every fiscal year.
Here is an example of what can happen to Medicare payments when the description used by the clinician does not match the patient’s actual diagnosis.
| Thoracic Surgery DRG Coding Scenarios | |||
| Patient’s Condition | DRG Code | Average Reimbursement for DRG Code Assigned | |
| Incomplete documentation of patient’s condition | Barrett’s Esophagus with high-grade dysplasia, transhiatal esophagectomy | 155 | $9,317 |
| Patient’s actual condition | Barrett’s Esophagus, with high-grade dysplasia, with CC, with transhiatal esophagectomy, such as:
|
154 | $22,955 |
| Cost to UMHS of improper coding | $13,638 | ||
In 2005, UMHS leadership examined our clinical documentation process with the long-range objective of improving cash flow, accounts receivable and the debt-to-cash ratio.
Here are the problems we found:
-
Because coders were located far from inpatient units, they used e-mail and phone calls to providers for additional information – methods that could be ignored in light of more pressing duties.
-
Because coders questioned clinicians about documentation after patients were discharged, clinicians had to rely on memory about patient conditions – much less reliable than at the point of service.
-
Clinicians’ responses to questions often were often inadequate due to the length of time between documentation and clarification.
-
When clarification was needed, coders talked with attending physicians instead of the documenting clinician (usually a new resident, nurse, nurse practitioner or physician assistant).
- Obtaining documentation post-discharge was difficult at best.
Solution – Closing the Medicare Reimbursement Gap
Most hospitals use registered nurses to assign DRG codes for clinical documentation. However, UMHS added specially trained coders – registered health information technicians – who would be the liaisons between clinical staff and clinical documentation.
Now:
-
An admission work list is generated to notify professional coding staff of an admitted patient.
-
Professional coders – not nurses – are permanently assigned to a clinical service. The specialized teams that understand specialized clinical services.
-
Cases are reviewed 24-48 hours after a patient’s admission in order to obtain a “working DRG.”
- Coders work directly with the actual documenting clinicians (attending physicians as well as residents, registered nurses, physician assistants and nurse practitioners, etc.) via e-mail or page and during face-to-face rounds on the units.
Our Program:
-
Captures the patient in the hospital – in "real-time" at the point of care. There is no backtracking, catching up or relying on institutional memory, to reconstruct the patient’s specific condition and coexisting conditions.
-
Educates clinicians. They learn the correct language to use to represent their patients’ conditions accurately.
-
Helps train residents for their future positions here at UMHS or at other hospitals across the United States.
- Adds value. The program decreases reimbursement denials, increases revenue, improves communications between coders and clinicians, and documents the patient’s condition thoroughly.
The End Result
The end result is that coders’ inquiries to clinical staff decreased by 41 percent – and accounts receivable increased.
| Queries to Physicians Via Phone and E-mail Every Month | ||
| 2005 | 2006 | Percent Change |
| 850 | 350 | 41% decrease in one year |
Enlarge Image
What This Means for Patients
Because professional coders at UMHS handle clinical documentation, and clinicians are being trained in terminology that correctly reflects their patients’ conditions:
-
Medicare charges are reimbursed more fairly.
-
Nurses spend more time on direct patient care instead of documentation.
-
Clinicians are trained in Medicare coding terminology used across the United States.
- Conditions are documented fully, which also aids with the patient’s future clinical care.
As Whitehouse, says, “What began as a project to enhance clinical documentation ended up as another way we enhance patient care.”
For More Information
For details about the UMHS Clinical Documentation Improvement Program, contact Rosanne G. Whitehouse, chief administrator, Health Information Management, University of Michigan Health System, at 734-936-9295.
To learn more about how the University of Michigan is committed to quality and appropriateness, contact John E. Billi, M.D., associate dean for Clinical Affairs, University of Michigan Medical School, at 734-936-5214, or Darrell Campbell Jr., M.D., chief of staff, University of Michigan Hospitals and Health Centers, at 734-936-5814.
For more detailed information on the medical terms used in this article, go to the University of Michigan’s Health Topics A to Z.
Posted August 2007
