“Doctor, please clarify: Is this type of congestive heart failure acute or chronic, systolic or diastolic?” Most hospitalists have had patients’ charts flagged with these types of queries. And no, the people who write the questions are not trying to be difficult.
In fact, says Karen Bachman, BSN, MHSA, director of clinical documentation at 300-bed Good Samaritan Hospital in Suffern, N.Y., the specialists who place worksheets on hospitalists’ charts are sympathetic to the perceived disconnect between clinical processes and the language of the coding world. Even for nurses, the ICD-9-CM, the manual upon which Medicare bases its reimbursement structure, “is a different language,” she says. “You have to think like a coder.”
And in the coding world, as the saying goes, “if it’s not documented, it didn’t happen.”
That’s where clinical documentation specialists come in. Collaborating with documentation specialists can help boost patient quality, hospital reimbursement, and your hospital’s recognition of the value your HM group adds.
Stephanie Jensen, RN, BSN, coordinator of the Clinical Documentation Integrity (CDI) program at The Nebraska Medical Center in Omaha, summed it up this way: The chart has become more than what it was originally intended. It’s now the repository of “the patient’s story. We’re just trying to help physicians capture the quality of care that they’re giving, and to make sure that, in the medical record, the documentation supports the severity of illness, risk of mortality, and overall clinical picture.”
—Stephanie Jensen, RN, BSN, coordinator, Clinical Documentation Integrity (CDI) program, The Nebraska Medical Center, Omaha
For example, even though nurses can stage a pressure ulcer, the stage must be accompanied by the hospitalist’s diagnosis of decubitus ulcer in order for the coders in the Health Information Management and Services (HIMS) department to properly code the diagnosis, which affects the DRG submitted to Medicare/CMS.
Bachmann thinks the biggest challenge to proper documentation is time. Hospitalists are immersed in caring for their patients. They must balance different coding systems—the ICD-9-CM, as well as CPT and E/M coding for their own billing. They often feel pulled between taking extra time to clarify their working or discharge diagnoses and getting on to the next patient. The catch, though, is that hospital coders can rely only on what the treating physician documents.
At Good Samaritan, documentation specialists see themselves as allies in this process. They use the JA Thomas documentation system and print out worksheets to attach to patients’ charts; it’s intended to be a trigger so that the hospitalist will be as specific with documentation as possible. “As nurses,” Bachmann explains, “we understand what physicians need and what the coders need. We’re an intermediary between the two.”
At The Nebraska Medical Center, the hospital’s mortality committee initiated a systemwide CDI program in November 2009. Jensen explains that every new staff physician at the 689-bed facility now receives a CDI toolkit detailing the documentation program. The six CDI team members wear blue T-shirts, and documentation clarification worksheets are on blue paper.
During monthly in-services at hospitalists’ meetings, says Bachmann, “we stress the importance of linking the etiology with the diagnosis. We illustrate how different diagnoses will be given different relative weights for DRGs.” The effort has proven to be an effective educational tool, she says.