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

Healthcare Financial Management, April, 2008

While Sentara regularly brings in external auditors for both inpatient and outpatient coding as part of its compliance program, the health system does not purchase outsourced labor for coding because of the expense, notes Swaim. Instead, the system employs coders who have more than five and closer to 10 years of experience, and it assigns one or more to work in a specific hospital depending on the needs of the facility.

In the system's general hospitals, coders work on all types of records. But at Norfolk General, Sentara's tertiary care hospital, one coder specializes in obstetrics because of the high number of infants treated in the neonatal intensive care unit and high-risk pregnancies. In addition, some coders specialize in cardiac care. In 2006 and 2007, Sentara added specialty coders for cardiac catheterization and interventional radiology because of the need to tie together documentation, billing, and coding for these areas. With such an arrangement, as soon as a case is documented, then the charges can be assigned and the codes can be matched to charges.

* Connecting the Feedback Loop

Data gathered through regular monitoring focus further training efforts. A biweekly conference call between onsite clinical documentation liaisons and remote coders for Sun Health flags problematic diagnoses or reporting areas.

Direct feedback to individual physicians as well as aggregate feedback by product line or service identifies opportunities for additional education at Sentara. From a random sample of inpatient records, St. Vincent Health reports trends and problem areas for nursing units or physician groups or service lines.

"We just grab any and every opportunity across the board," Funsten says. "We look at every chance to educate, from a hallway chat to a formal 30- to 45-minute training session to a lunch-and-learn session."

Software programs that track and trend data can help guide training efforts by generating monthly DRG monitoring reports as well as regular severity-of-illness and risk-of-mortality profiles.

But automated systems for alerting physicians about discrepancies or for streamlining the reporting process for the most part are still in the making.

"Any time you build anything with alerts, you have to make it selective enough so it doesn't become a bunch of white noise. So you have to tread softly to start," notes Swaim.

Sentara is in the process of launching an electronic health record project; the system just recently went live in its first hospital. The system includes documentation tools and built-in prompts that ask physicians to include certain descriptors as they create their progress notes. For example, they may be asked to describe whether a patient with CHF has left or right heart failure. Also, the system has capability for electronic messaging to allow for improved speed and rates of response to queries by physicians. In addition, the project incorporates some automated tools to assist coders, such as access to online coding clinics and national coding publications.