Improved documentation: leveraging staff training, benchmarking, technology, and process change for accurate payment

Healthcare Financial Management, April, 2008

[ILLUSTRATION OMITTED]

Providing adequate detail in medical records for billing may seem relatively unimportant when compared with the attention physicians must give to providing high-quality patient care. Yet this task isn't one to be taken lightly.

Helping physicians dot the I's and cross the T's has never been more important, as new coding rules are changing the definition and calculation of payment and external groups are comparing and contrasting the performance of individual providers, point by point.

* The Need to Improve Clinical Documentation

Concern about the financial fallout from the shift to severity-based diagnosis-related groups is very real, particularly when today's hospitals already are facing payment challenges.

Such is the case at Sun Health Boswell Hospital in Sun City, Ariz. The 501-bed hospital has an 80 percent Medicare population, an average patient age of 70 years, and inpatients with multiple comorbidities and complications (CC). The latest increase from the Centers for Medicare and Medicaid Services (CMS) was less than 1 percent.

"We always seek good quality documentation," says Nancy Burton, CEO of Sun Health Boswell Hospital. "However, when you're faced with stagnant or further possible reductions from major payers, it is critical that you exhaust all opportunities to improve the accuracy of documentation."

But declining payment is not the only reason why hospitals are seeking to improve clinical documentation. The way they appear in public data is another driver.

Groups such as Thomson Healthcare and The HCIA-Sachs Institute scrutinize data from public sources, such as the Medicare Provider Analysis and Review (MedPAR) data set, CMS Standard Analytical File, outpatient data, and Medicare Cost Reports, to identify the top hospitals in the country on the basis of such clinical metrics as risk-adjusted mortality, complications, patient safety, core measures scores, and severity-adjusted average length of stay. And they highlight key differences in performance, including shorter average lengths of stay and lower costs per case, for the top performers.

Also, HealthGrades regularly analyzes data from Medicare discharges from all U.S. hospitals to profile the quality of care at the national, regional, and state levels, and it ranks individual hospitals from best (5-star) to poor (1-star) for particular disease conditions or surgical procedures.

Hospitals are becoming increasingly sensitive to the story that these public data files are telling managed care companies and consumers. Do the final billing codes that come directly from physician documentation indicate a hospital has patients with less severe conditions, longer lengths of stay, and higher costs than peers? If so, why would managed care companies want to send their enrollees to that hospital when they can find another institution that treats sicker patients in shorter periods of time at less cost and with good outcome results?

"Our need to make sure we are following coding guidelines correctly and capturing every detail we possibly can has been heightened not only by the demands we place on ourselves, but also by external demands for quality information reporting," notes Roland S. Funsten, FHFMA, vice president of finance and revenue cycle for St. Vincent Health, a healthcare system that includes 17 hospitals in and around Indianapolis, Ind.

"There's still the demand for prompt turnaround on payment, billing and processing, and bill payment," he says, "But there is also increased demand for taking the time to make sure we have adequate supporting documentation on file to improve reimbursement to the highest permissible level and to look for opportunities to capture better and more succinct information about the diagnoses or conditions that affect a patient's stay in the hospital or their care."

Hospitals consequently are turning to concurrent documentation programs that evaluate the content of medical records to see how well they assign DRGs, severity of illness, and risk of mortality, to teach physician documenters and inpatient nurse reviewers about Medicare reporting and coding requirements, and to monitor documentation and coding performance, case-mix index, and CC rates. And they are increasing their case-mix index, rate of reimbursement, and DRG-weighted ratios as a result.

* Sun Health Del E. Webb Hospital

In late 2006, the Sun Health Del E. Webb Hospital in Sun City, Ariz., (a sister facility to Sun Health Boswell Hospital) was not sure documentation truly reflected the care of its patients. An internal chart review suggested that coders weren't picking up the detailed level of data that was needed to bring the hospital's clinical core measures up to the benchmarks it had set for itself. The hospital's goal was to be in the top quartile for all CMS core measures. But for some measures, it wasn't even reaching the average for the state or for the nation.

"As we looked at some of those variations, we began to ask ourselves, 'Have we gotten sloppy with the documentation work that we're doing?'" recalls Jo Adkins, CEO of the 332-bed facility. For patients with congestive heart failure, for instance, were they being discharged on angiotensin-converting enzyme (ACE) inhibitors, and if they weren't, why not?