Tuesday, April 30, 2013

A Documentation Improvement Success Story

A Documentation Improvement Success Story
By Judy Sturgeon, CCS
For The Record
Vol. 23 No. 8 P. 8
Is your documentation everything it should be? Are your physicians providing all the information your coders need for accurate coding and reimbursement? Will the information be good enough when ICD-10 is implemented? Has your budget prevented you from enlisting help from a top-shelf consultant’s clinical documentation improvement (CDI) program?
There is a viable solution. Just ask the HIM department at Monroe Clinic, part of an integrated clinic-hospital organization licensed as a 100-bed hospital with an 80-provider multispecialty clinic in Monroe, Wis., and 11 community clinics in southwest Wisconsin and northwest Illinois.
Regardless of a facility’s size, several issues are crucial for all HIM departments. Monroe’s HIM department has the same needs and concerns as the largest university or national medical conglomerates: good documentation, ongoing communication with physicians, improved coding, and a positive response to a staggering number of industry changes.
Laurie Schimek, RHIT, Monroe’s HIM manager and privacy officer, says it was a whirlwind experience as the clinic attempted to take better control of its documentation practices. By addressing its needs one step at a time, Monroe has been able to keep on top of healthcare’s shifting landscape. In 2009, after converting its coding from paper documentation to a new EMR, Monroe began discussing ways to improve physician documentation in the new system.
Rather than enlist help from a vendor, Monroe felt it was imperative to create its own documentation improvement project. The reason? “We had a need to communicate. We already have the knowledge, and we know where the needs are,” Schimek says. “We identified what we did know and built on that. Then one of the inpatient coders volunteered to go talk to the hospitalists to help clear up some of the documentation questions.”
For the project to have any chance at succeeding, Schimek says gaining support throughout the clinic was critical. “We’ve been extremely fortunate in having leadership who consistently provide excellent support and have confidence in our knowledge and ability,” she says. “We quickly received buy-in from the director of information services to whom we report and from both the chief financial officer and the chief medical officer. Our initial outreach coder did her homework, too, by researching the basic concepts and needs involved in order to create an effective and compliant clinical documentation improvement program.”
The project may have seemed overwhelming, but the extensive requirements for the final product did not discourage Schimek, who recalls telling the novice CDI coder, “Let’s just look at this as an experiment. Introduce yourself; ask if there’s anything you can do to help them [physicians].”
By keeping the immediate task at hand manageable, Monroe forged ahead toward its ultimate goal.
“We don’t have any extreme extroverts here,” Schimek says. “Our first few meetings included some white-knuckle moments for our coder, but she began her first encounter by explaining the need to understand why physicians documented as they did. The coder included clinical examples of how their documentation affected the physicians’ level-of-service coding. Then she asked if they had any questions for her and once the dialogue began, there was no stopping it.”
Schimek says the idea was to create a peer relationship with the physician staff. It turned out to be beneficial for both sides, a positive experience that offered assistance to physicians as well as to the coding department. Schimek says several strategies were employed to create this cooperative effort.
“We went in to understand, not to tell them what to do,” she says. “We stopped using punitive and threatening words like ‘audit’ and ‘benchmark’ and ‘review.’ We wanted to develop an interactive relationship, so we created in their place interactive coding sessions and encouraged a peer role relationship. We made certain that our clinical examples were not identified by physician, only by the documentation issue that was of concern. We maintained an attitude of respect and we receive respect in return.”
In addition to these behavior changes, Monroe’s CDI coders created personal business cards and bumped their dress code up a notch to reflect their competence as clinical professionals. “You can’t let clothing cause you to be prejudged,” Schimek notes.
Rather than try to tackle everything at once, the CDI program focused on each department’s top five issues and required that a coder was available for 15 minutes at regular department meetings. As documentation needed clarification, coders jotted down the basic issues daily. At each meeting, the top five reoccurring items were brought to the attention of physicians and staff. As the physicians became more attentive to the most pressing problems, new ones were introduced.
Arrangements were made for a coder to participate in daily rounds, and the medical staff’s demand for her input quickly increased as more departments opted into the program. One skilled coder representative soon became several with a little time and training. Eventually, the program expanded to address outpatient clinic needs as well as inpatient concerns.
One step on a tentative path, created by need and fueled by a coder champion with little nerve and built on a foundation of good planning and cooperation, has brought significantly more to the clinic than some basic documentation improvement.
Letters of commendation from the hospitalists to the chief medical officer further validated the project’s value and gained esteem for the coders and the department as a whole. Meanwhile, case mix has improved noticeably. Trepidation surrounding recovery audit contractor audits has subsided thanks to the improvement in specific and detailed documentation. The thought of a new ICD-10 coding system and its expectations for greater documentation detail is less intimidating.
In addition to those benefits, the program has enhanced employee satisfaction, an important accomplishment in an environment where there is increased demand for competent coders. In fact, the project’s original coder champion has been promoted to coding supervisor.
“Our confidence levels have improved noticeably all around. As awareness of the knowledge and capability of the coding staff spreads even wider, their self-esteem and respectability continue to increase along with their reputation,” Schimek says.
Monroe Clinic has succeeded in turning reaction into action, initiating change rather than waiting around to find out how badly change will affect them. Their world is no longer a static environment. It’s an exciting place to work and an example to other facilities that a generous portion of ‘will do’ can become a successful story of ‘can do.’
If you’d like to learn more about the Monroe Clinic CDI program, visit www.monroeclinic.org or contact Laurie Schimek at laurie.schimek@monroeclinic.org or 608-324-2192.

 

Please contact ERM for more information about on-site and remote training. Education is the only solution. 772-210-2823 or kgifford@ermconsultinginc.com

CMS Restructures RAC Program: Five RACs, Not Four

CMS Restructures RAC Program: Five RACs, Not Four
Beset by legal challenges and a burdensome backlog of pending appeals, the Centers for Medicare & Medicaid Services (CMS) is implementing sweeping changes to its Recovery Auditor (RAC) program, as evidenced by documents obtained by RAC monitor.
Among those documents is the request for proposal (RFP) issued by CMS for the re-procurement of recovery auditor contracts. As reported here recently, PRGX Global, formerly known as PRGX Global-Schultz and currently a subcontractor to three RACs, is among those known to have submitted an RFP in hopes of becoming a prime RAC contractor.
Current RAC contracts are expected to expire in February 2014. The deadline for RFP submittal was April 4, 2013. The new RAC contract period is to extend from 2014 to 2018. 
The most sweeping of all anticipated changes is that CMS will have recovery auditors in all four geographical RAC regions, as currently configured, with a fifth “nationwide” RAC responsible for identifying overpayments among home health hospice facilities and durable medical equipment (DME). 
Under the plan, the four regional RACs no longer will handle improper payments for home health, hospice or DME.
Still another change to the RAC program is that CMS is requiring recovery auditors to support the agency throughout the entire appeals process, including at the administrative law judge (ALJ) level. According to its 2013 Statement of Work (SOW), CMS writes: 
“For any Recovery Auditor-identified improper payment that is appealed by the provider, the Recovery Auditor shall provide support to CMS throughout the administrative appeals process and, where applicable, (during) a subsequent appeal to the appropriate federal court. This includes participating or taking party status at the administrative law judge (ALJ) level of appeal in a minimum of 25 percent of the cases that reach this level.”
“The RACs will also now be required to participate and support CMS to defend against provider appeals,” Emily Evans of the Nashville, Tenn.-based Obsidian Research Group (ORG) wrote in a memo to investors. “The time frame for completing claims reviews is cut in half, from 60 to 30 days, and the new program will give CMS more teeth to stop work with a contractor that does not follow guidelines.”
CMS has been under siege on two fronts recently: first via the lawsuit filed in federal court on Nov. 1, 2012 by the American Hospital Association against the U.S. Department of Health and Human Services, and second, the recently proposed legislation by U.S. Rep. Sam Graves (R-Mo.) and Rep. Adam Schiff (D-Calif.), who introduced the Medicare Audit Improvement Act of 2013 (HR 1250) on March 19, 2013.
Evans writes that while ORG believes the changes to the RAC program are “not favorable in the short run,” the company believes that long-term opportunities remain “robust.”  
About the Author 
Chuck Buck is publisher of RACmonitor. 
Contact the Author 
cbuck@racmonitor.com This email address is being protected from spambots. You need JavaScript enabled to view it.
To comment on this article please go to editor@racmonitor.com This email address is being protected from spambots. You need JavaScript enabled to view it.
References 
Recovery Audit Scope of Work
Statement of Work for Recovery Audit Program (DME) Home Health and Hospice
RAC Regions

CMS updates NCD with ICD-10 codes | ICD10 Watch

CMS updates NCD with ICD-10 codes | ICD10 Watch


CMS updates NCD with ICD-10 codes

The Centers for Medicare and Medicaid Services (CMS) has updated its national coverage determination (NCD) edits to include ICD-10 codes.
The NCDs define what Medicare will cover. These updates will help healthcare providers determine how reimbursements may changed after Oct. 1, 2014.
Here's the list of files with explanations and the actual changes: