At Summit Healthcare Regional Medical Center, a small, rural hospital in Northern Arizona, there’s more than a little extra revenue going around after the implementation of a clinical documentation improvement program. Run by a team of nurses, including Mandy Rogers, RN, the program has helped to squeeze more than half a million dollars of legitimate reimbursement out of the hospital’s revenue cycle after the implementation of a computer-assisted clinical documentation improvement package, changing the way physicians and coders work together to achieve better data, better communication, and better financial results.
“We are a pretty small hospital,” Rogers said to HealthITAnalytics. The 89-bed hospital cares for around 90,000 patients spread across 3000 miles of the rural Southwest, including Native American reservations. “About a year and a half ago, we decided that with all the changes coming from Medicare and the RACs, we needed to be a little bit more defensive about our money that was going in and out. So we decided to start a CDI program from the ground up about a year ago. No one had ever done it. I was a floor nurse, and my partner in crime had done auditing and other things like that before, and she has also been a nurse for 40 years.”
“At the moment, we are half paper and half electronic, which is really frustrating,” she added. “We have doctors that dictate reports to be transcribed. We have doctors that handwrite them in the charts still. So, we are all over the place. We do part of our review at our desks, and then we go to the floor with laptops and we review the rest of the charts that are hand written. It quickly became clear that we needed some kind of electronic way to do this, because the manual recordkeeping was awful. It took forever, and it was really hard to do. We are excited about the day when everything will be dictated and we won’t have to do that.” In the meantime, Summit had to select a CDI vendor that would help the hospital plug gaps in their revenue cycle. After exploring several options – some of which were disinterested in working with such a small organization – Rogers picked a vendor that provided enough support to allow the hospital to jump head-first into its improvement efforts.
“One of the things that we hit pretty hard at first was what changes to the documentation were going to change our DRGs,” she explained. “What was going to get us a major complicating condition (MCC)? We focused on those things and really just did the rudimentary queries about things like pneumonia. What kind is it? That changes your DRG this way or that way. So, we really just focused on that.”
By starting with these little changes, Summit has seen big results. In the first year of the program, the hospital has increased its case mix index by an average of 20 percent. MCC capture is up by 37 percent, and the complicating condition (CC) capture rate has increased by 22.8 percent, producing an overall positive financial impact of $558,187 in just a few months.
“Our administration and our board have been really good about supporting our CDI work,” Rogers said. “We knew that we when you’re growing a CDI program, it’s incredibly important that you show how your efforts are working so that your executive leaders will continue to pay for the program. So we really needed a reporting mechanism to be able to do that. We showed those good results right off the bat, and they’ve been happy to continue putting money into it.”
Achieving such notable gains in a tight time frame is an accomplishment in and of itself, but it also positions the hospital well for the impending transition to ICD-10, despite the series of delays and push-backs that has made many organizations dubious that the new codes will ever come into play.
“Our CDI work was a lot about ICD-10,” Rogers acknowledges. “When I first started, I did all that training. And we were really going heavy at it and doing education. And then, when they pushed it back, we were like, ‘Oh, okay.’ We were going to keep going and then it kind of seems—now a lot of people are saying they don’t think it’ll even go this year. Because it never has. When ICD-10 took a backseat, we were able to just focus on what we’re doing now and get good at that.”
That may have been a wise strategy for Summit, considering how averse many physicians are to hearing about the changes in workflow that will be required because of the new codes. Framing clinical documentation improvement as a purely financial issue that has nothing to do with the burdensome ICD-10 mandate that inspires such strong opinions can be an effective way to get busy clinicians on board. Physicians want to be sure that they are capturing the severity of their patients appropriately for many reasons – not least because it makes them look better to their superiors and their peers.
“I think physicians right now, as a whole, are being inundated with so much,” said Rogers when asked how Summit’s physicians have viewed the CDI program when it’s put through the ICD-10 lens. “No matter where you go, you’re going have a few of those doctors that go, ‘Oh, no more. Please.’ It is helpful that this is a small hospital, and that I see these doctors all the time in the hall or in the cafeteria. I worked here for seven years before this. They know me—that is helpful when I’m asking them to change the way they’re doing things. Our doctors have been pretty open to the whole clinical documentation improvement process. When we’ve explained to them what we’re doing and why we’re doing it – if we’re querying them, it’s because it’s going to change something.”
For much of the time, that “something” is simply a matter of ensuring that physicians and coders are speaking the same language. Clinical documentation often turns into a game of Telephone as the chart passes from the patient’s bedside to the HIM office, which can be a major source of confusion and inaccurate coding that lets reimbursements trickle by.
“Most of the issue that I’ve seen is a difference between “doctor-speak” and the language of coding,” agrees Rogers. “Sometimes the physicians don’t quite get the difference between what the coders do and what we do, and they don’t always get why we’re querying them. That’s where I’ve noticed the biggest gap of understanding. But because we’re so small, I can go up and talk to them or I can go to a CDI team meeting and find out what the problem is. Or I can go talk to the patient’s nurse on the floor and kind of get an idea of what’s going on.”
“We’ve had good feedback with our program,” she continued. “I’ve had the doctors say that they like the queries. I’ve had doctors that copy them and take them home because they learn from them. We told the doctors, ‘Pay attention to the queries when you’re answering them, because this will tell you what you need to document next time. And then you won’t get a query.’ We also worked a lot with our coders about what they saw on the back end: things we could try to change on the front end of things and try to catch before it gets to the coders.”
These efforts to improve communication, make queries quick and relevant, and bring together both sides of the documentation equation have produced remarkable and tangible results for the small hospital, thanks to a well-planned approach assisted by health IT, Rogers said.
“One of the biggest boosts was the CDI software that we got. Because it really guides you and it helps you keep track of what you’re doing. The other thing was that we got a four-day boot camp that our vendor brought. It taught us everything we needed to know; it gave us books that we still use right now, every day.”
“Having that really good foundation of education is really important, because CDI was such new animal to us,” she continued. “I think that’s helped us so much. Keeping the doctors informed and involved is also helpful. Making sure you’re giving them good queries is important, so that you’re not annoying them all the time and they’re not confused by what you’re trying to get at. So, we still have a lot of work to do. We still have a lot of room to grow and things that we want do. We want to start looking at the severity of the illness and risk of mortality next. And getting our encoder put on so that we can start moving forward even faster.”
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