Clinical Documentation Improvement Program Inpatient Setting Our Implementation Journey

Transcription

1 Clinical Documentation Improvement Program Inpatient Setting Our Implementation Journey Linda Dubiel, RHIA, Coding Director Mayo Clinic Health System NW WI Region WHIMA Conference May MFMER slide-2 1

2 Clinical Documentation Improvement CDI programs have been around since the 1990 s Concurrent Coding model We tried concurrent coding in 1990 s but went back to post discharge due to the time required of the coder on the floors in addition to finalization after discharge. MS-DRG Effective 10/1/2007 CMS implemented MS-DRGs Added d an additional level l of severity to differentiate patients with additional comorbidities/complications (CC) requiring greater resource consumption. We wanted to make sure our inpatient coders were capturing all appropriate codes. In 2008, we were contacted by an external physician consultant company. 2

3 Clinical Documentation Improvement Inpatient Coders Hired an external physician consultant to provide education for inpatient coders to ensure the accuracy of coded data. 12 month project Retrospective physician query process with standardized query forms Enhanced coders clinical knowledge of pathophysiology and various disease processes. Physician education of the IPPS payment system, severity adjusted DRG s and present on admission (POA) Assignment & training of a physician liaison for coders Assignment & training of coding auditors (2 Inpatient Coders) 3

4 Success! The project proved to be a success. Physician documentation improved more specificity representing a more accurate picture of the patient s level of severity and more appropriate reimbursement. Coders clinical knowledge enhanced - more appropriate queries when documentation needs clarification Decrease in number of queries coders send to providers post discharge Case Mix increased Retrospective Documentation Review While project was successful, retrospective review wasn t ideal Attempts to clarify documentation were problematic -patient was discharged & physician not always familiar with case anymore. Delay in final coding and billing due to length of time it took for some physicians to respond to queries 4

5 Inpatient CDI Focus Inpatient CDI focus changed from reimbursement optimization to accurate representation of severity of illness and risk of mortality. Benefits of concurrent documentation review versus retrospective became more apparent Documentation specialist could have face-to- face discussions with providers & obtain clarification at point of care, minimizing clarification requests needed by coders after discharge. Mayo Clinic and Mayo Clinic Health System The Power of Collaboration Inpatient CDI program in place at Mayo Clinic s three group practices in Minnesota, Florida and Ai Arizona Revenue Cycle houses the CDI program for Rochester which has been in place for approximately 3 years. As the plan for ICD-10 implementation began to be discussed, a decision was made to use the CDI specialists to educate inpatient t providers about the increased specificity required for ICD-10. CDI programs would be implemented in all hospitals in the Mayo Clinic Health System. 5

6 Clinical Documentation Improvement Mayo Clinic Health System NW WI Region DCBA, Inc. is consultant hired throughout the Mayo system to implement a concurrent documentation review program and train CDI specialists We created a CDI specialist job description for our NW WI region o Qualifications and education required Active Wisconsin RN license or ability to practice professional nursing in the state of Wisconsin Bachelors of Science Nursing (BSN) degree from an accredited university Masters preparation and/or advanced course work preferred Five years working experience as a Registered Nurse in acute care setting, preferably in CCU, Med/Surg, ED Must obtain or be willing to obtain advanced training and certification in clinical documentation improvement within 24 months (CCDS). Utilization Review/Case Management or ICD coding experience preferred How we got started 4 CDI RN FTE s approved for NW WI Region (One 230 bed PPS hospital and 4 CAH sites) PPS hospital and 4 CAH sites) Support from administration and Medical Director Communication about the program with providers and department directors from Medical Director Nurses hired and trained DCBA 2 day boot camp and 10 week subsequent training October 2012 January 2013 ICD-9 coding Intense A & P and pathophysiology of disease all specialties Physicians and midlevel providers attended presentations specific to specialty by DCBA 6

7 New CDIP Program CDI nurses review documentation on floor paper progress notes Paper clarification forms. Not a permanent part of medical record. Documentation is amended. Midas CDI module (software that tracks, manages and reports data) - still working on building our reports CDI nurses enter cases into Midas as well as scan their clarification forms and save them in Midas. Coders save their retrospective queries in Midas and have access to the CDI info and CDI nurses have access to the coders queries. CDI nurses work closely with inpatient coders and meet monthly to discuss cases CDI nurses are developing relationships with case managers and core measure abstracters in Quality Monthly conference calls with Mayo enterprise CDI nurses CDI nurses are members of WI ACDIS and attend monthly conference calls Inpatient CDIP Future CDI nurses continue to learn more about documentation review and coding guidelines Develop relationships with providers and other departments Measure and track physician compliance, CDI productivity, SOI (severity of illness) and ROM (risk of mortality) Take the CCDS exam after 2 years experience 7

8 Questions? Linda Dubiel, RHIA 8