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Improving Clinical Documentation

August 15, 2011
by Jennifer Prestigiacomo
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A Kentucky hospital takes steps toward ICD-10 compliance and makes clinical gains along the way

After Starla Stavely took her position as health information management director at Jennie Stuart Medical Center (JSMC), a hospital with just fewer than 200 beds in Hopkinsville, Ky., she performed a financial and coding assessment that showed healthy room for improvement. Not only was there room for growth in coding accuracy among clinicians and coders, there were monthly revenue opportunities to be gained.

Stavely’s entire revenue cycle analysis examined JSMC’s case mix and top 10 diagnosis-related groups (DRGs), as well as the payer mix for medical/surgical services in the hospital. The analysis also took a look at the top physicians in the hospital and their types of case mix and patients’ lengths of stay. The assessment also revealed that the percentage of unbilled charts was outside standard limits, which opened the organization up to a wealth of revenue opportunities. Statistics indicated that the diagnoses and procedures being documented by clinicians were not reflective of the severity of illness of their patients or of the length of stay involved. As a result, the hospital’s case mix index was below expectations for the type of patients being treated at JSMC.

Instead of employing a consulting firm to direct a clinical documentation improvement program that could cost, as she says, in the range of $100,000 to $500,000, and possibly involve a long engagement contract, JSMC opted in December 2010 to select a software solution, from the Wakefield, R.I.-based Chartwise Medical Systems, to help tighten its coding system. The web-based software operates with an HL7 admissions discharge transfer (ADT) feed that pulls in the patient demographics and pre-populates the information in the system, and updates it if anything changes during the admission. Because of interfacing limitations of JSMC’s electronic health record, different diagnostic values like EKG results, diagnosis codes, and lab results don’t flow directly into Chartwise, and must be entered in by clinical documentation specialists. The software reviews existing diagnoses, procedures, lab values and medications, and offers additional diagnoses for the clinical documentation specialist to consider and offers standard and customized electronic physician queries to help eliminate ambiguity.

The company says that in the near future, the system will be able to pre-populate any diagnoses that are already in the EHR using HL7 BAR (Billing Account Record) messaging. It will also be able to pull in the final billed codes from the billing department to reduce data entry and facilitate metrics.

Clinical Documentation Improvements
From this software implementation have come many improvements for JSMC in clinical documentation and revenue cycle management. Through the clinical documentation software, Stavely does weekly and monthly impact reporting for senior management that shows the top 10 DRGs, overall case mix, query rates, and other metrics. The query reports allow Stavely to measure the number of queries and how many were responded to, as well as which physicians might need additional coding training, and which physicians don’t need to be queried anymore.

Certain unintended benefits have come to light since deployment as well, for example, when there is difficulty identifying why particular physicians have patients with above-average lengths of stay. In such cases, the software is able to pinpoint which patients have been incorrectly coded with a less serious DRG, and as Stavely says, gives credit back to the physicians for the work they’re doing.

“When the impact of a query isn’t what we expected, it often helps us identify where some coding education is needed,” says Stavely.


Starla Stavely

ICD-10 Compliance
Stavely says the clinical documentation software will be the backbone of JSMC’s ICD-10 compliance plan. In the future the software will provide suggested ICD-10 codes. “It will be a tremendous help in our ICD-10 prep & transition,” she says. “It’s going to be an integral part [of our plan]; not the least of which is how much physicians learn just from reading the queries. They will be able to see just how specific we need things to be for ICD-10.”

At the beginning of next year, Stavely’s department will be taking anatomy and physiology courses to prepare to transition to the detailed nature of ICD-10. She says she’ll also be working on her organization’s ICD-10 impact analysis, which will call for a multidisciplinary steering committee to meet regularly and lead the effort. JSMC’s coding training won’t go full-throttle till April 2013, when coders will start practicing dual coding processes, starting with the top 20 DRGs.

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