With all of the changes taking place in health care, it's not easy for providers to decide where to focus time and resources: whether to improve quality of care, ensure compliance or safeguard revenue integrity. Nonetheless, regulated changes like ICD-10 and value-based purchasing have shown that clinical documentation can help many a CFO or other health care executive to sleep better at night.
Medicare is asking for deeper insight into the medical record. It wants to ensure that physicians' thought processes are correct and that they are following through on those processes. Medicare also wants to ensure that the documentation physicians create supports what they are being appropriately reimbursed for. This, in turn, is forcing providers to get physicians to take all the processes and assessments they're thinking about and capture them in clinical documentation. In general, physicians are doing this, but they haven't been capturing every detail in the medical record. They need to start doing that.
What a good clinical documentation improvement, or CDI, program does is to ensure that physicians translate the care provided in their minds into actual documentation. This documentation follows patients from the time they present themselves to the hospital all the way through discharge:
- why a physician believes a particular disease is manifesting itself within a patient;
- a determination as to the particular treatments;
- how a patient responds to treatment in the hospital;
- discharge and transfer of care.
Getting physicians to capture this level of detail without drastically impacting productivity is difficult, but it can be achieved with the right strategy; approach to physician engagement; and integration of intelligent, physician-friendly technology.
A CDI Success Story
Baptist Health South Florida is the region's largest nonprofit health care organization, with more than 13,000 employees working in six hospital campuses and multiple satellite locations. When I came to the Baptist Health system, I noticed that there were opportunities to improve the documentation, quality metrics and utilization benchmarks. With past involvement in a successful CDI program, and with the transition to ICD-10 weighing heavily on my mind, I recommended a comprehensive CDI program to improve quality benchmarks, case mix index and appropriate reimbursement through more thorough, specific physician documentation.
While many hospitals hire nurses to fill clinical documentation specialist roles, I chose to fill the majority of these roles with physicians who were already a part of the staff. By using peers to provide guidance on clinical documentation, I established a higher level of credibility and respect, and I minimized the physician resistance I sometimes encounter as part of a traditional CDI program.
Baptist Health has a number of international physicians working as house physicians. Recognizing the quality of their backgrounds and their importance to our success as an organization, I offered them the position of clinical documentation improvement specialists. In addition, I chose Mauricio Palma, M.D. — an international medical graduate with an MBA and experience in managed care, medical management, case management and utilization review — to direct the clinical documentation improvement program.
Baptist Health South Florida's CDI program, known as "CDI Miami," is structured in a way that meets the cultural and institutional needs of our health system. With 15 full-time documentation specialists (one critical care nurse and 14 international medical grads), Baptist Health South Florida educates hospital physicians on the importance of accurate clinical documentation and how this accuracy not only helps the hospital, but also impacts their own professional profiles on such websites as Physician Compare. Baptist Health South Florida's CDI Miami specialists are on the floor providing one-on-one education with physicians as much as possible to discuss or clarify documentation concurrently.
Preparation for ICD-10 Coding
CDI Miami is strong and gaining momentum as the ICD-10 transition approaches and the implementation of Medicaid All Patient Refined Diagnostic Related Group payment begins. Today, physician agreement response from all of our hospitals to our CDI Miami queries is more than 90 percent, which reflects the buy-in we have from our physicians. They understand the myriad implications related to quality clinical documentation, including the positive or negative impact it can have on their own private practices. Considering the competitive environment physicians find themselves in, it is imperative that they are seen positively on public reporting sites, and concise documentation impacts their stature in these reports.
CDI Miami will be increasing the number of its specialists in response to ICD-10 and Medicaid's changing its payment methodology to APR-DRG. Physicians and hospital executives are requesting education from our CDI Miami specialists to help address this change. Considering the projected revenue and productivity losses associated with the transition to ICD-10 and the complicated Medicaid APR-DRG payment system, there is little disagreement regarding the expansion of our CDI program from our executive team.
At Baptist Hospital of Miami, specifically, the baseline Medicare case mix index prior to implementation was 1.56; the Medicare fiscal 2013 CMI now stands at 1.74. Improvements in our CMI are a direct reflection of our physicians' ability to capture the severity of illness of our patient population, which allows for correct and appropriate reimbursement and positively impacts our bottom line.
To ensure ongoing improvements to our CMI, we are making a number of adjustments and enhancements to our CDI Miami program. The CDI Miami team is using Web-based education modules and dual coding for APR-DRG and ICD-10. This will help us to identify which specialties and physicians are most impacted and why. In addition, Paul Weygandt, M.D., a consultant with Nuance Communications, is providing educational sessions to our physicians on clinical documentation best practices.
The CDI Miami team will continue supporting and educating our treating physicians in ICD-10 and APR-DRG. As a result of our continuing education, the greater requirement for additional specificity documentation in ICD-10 and Medicaid APR-DRG will come as no surprise to our physicians.
Culture of Continuous Improvement
At Baptist Health South Florida, we also use our CDI Miami program for quality control. For example, the CDI Miami team reviews charts that were flagged by Medicare recovery audit contractors for medical necessity. They review those charts and determine whether the CDI Miami team reviewed the patient. Ultimately, we want to know if we could have done something to avoid the RAC audit. This review provides an opportunity to train the staff to document care more accurately to avoid similar audit situations in the future. Every week, the CDI Miami team receives a list of RAC audits that have arisen; together, we analyze, adjust and strive to improve our program.
Baptist Health South Florida regularly acknowledges the work of its CDI Miami program. The physicians and CEOs of our hospitals always make a point to applaud the CDI Miami specialists for the hard work they are doing. Considering the high costs of care and growing fears of lost reimbursement, it's easy to focus on the positive financial impact our CDI Miami program has had on the institution. Still, we have not lost sight of the critical patient care implications.
The CDI Miami program helps to protect patients by ensuring that details specific to their personal health and well-being are contained in the record and, therefore, that every physician who touches that medical record has access to each patient's complete story. When that patient takes his or her medical record across the country to start a new job, the patient's new physician will have a 360-degree view of past care and current health and wellness.
As health care providers work diligently to balance quality, compliance and revenue integrity, they must place more emphasis on capturing complete clinical data that can be shared throughout the care continuum and relied upon when it comes time for reimbursement and/or audit.
Lorena Chicoye, M.D., is the corporate medical director of managed care, network development and medical management, at Baptist Health South Florida. Mel Tully, senior vice president of clinical service and education at Nuance contributed to this article.