Clinical Documentation Improvement: A Work In Progress Joy Jackson, MD Bobbi Tadwalt, RHIT Lakeland Regional Medical Center This

paper outlines the creation of the documentation improvement program at Lakeland Regional Medical Center (LRMC). LRMC is a not-for-profit, 851-bed acute care facility located in Central Florida, making it the fifth largest hospital in the state. In 1999, LRMC began to concentrate on improving the quality of the documentation contained in medical records by hiring Joy Jackson, MD, as physician advisor. This was prompted by data analysis that showed a decreasing case-mix index. Comparison to other VHA hospitals showed a lower than expected complications and comorbidities (CC) rate and severity levels. This concerned upper management because anecdotal evidence suggested the data did not accurately reflect the severity of illness in the elderly patient population served by LRMC. In September 2001, Bobbi Tadwalt, RHIT, joined LRMC as clinical documentation coordinator. This position was created to investigate opportunities for documentation improvement, perform concurrent chart review, and to provide physician education on documentation and coding related topics. With support from the hospitals Operational Leadership Team, the first pilot project began in November 2001 with a focus on pneumonia. Pneumonia Documentation Project Potential pneumonia patients were identified the day following admission with a report listing all new admissions and diagnoses or symptoms. The study excluded pediatric patients, while including patients admitted with shortness of breath, non-cardiac chest pain, or infiltrates on x-ray. Patients with a diagnosis of pneumonia or COPD exacerbation were reviewed as well as elderly patients whose conditions were suspicious for pneumonia (dysphagia, weakness, dehydration, altered mental status). These patients were entered into a database for tracking purposes. Once the patients were identified, charts were reviewed on the floor for possible pneumonia and supporting documentation. Prompter forms were placed in the progress note section of the chart if documentation did not clearly support the treatment being provided to the patient. The initial prompters (Appendix A) asked the physician to document whether or not pneumonia existed (if the clinical picture was not clear) and if so, to be as specific as possible when listing pneumonia as a diagnosis. The chart would be reviewed daily for physician response. In addition, if the physician was available, documentation was discussed with him or her. The prompter form remained in the chart until it was coded. The coders would indicate the final DRG and whether or not any additional documentation resulted from the prompter. The completed forms were collected and the results entered into the database. Nursing staff and case managers were asked to notify our office if they saw a pneumonia patient without a prompter on the chart. An informative poster about pneumonia documentation and the prompter form was placed in the physician lounge. Pneumonia documentation was discussed in our newsletter, The Doctors Forum. We attended service meetings explaining the project and discussing other documentation principles.

AHIMA Conference Proceedings, 2002

Results This study ran for 10 weeks during the peak pneumonia admission period at LRMC, and the study results were compiled (Appendix B). In all, 330 unique charts were reviewed concurrently with prompters being placed on 128 (38.8 percent) of those charts. The prompters were returned for 102 (30.9 percent) of those charts. Table 1 DRG Reference
DRG DRG DRG DRG 79 80 89 90 Respiratory Infections & Inflammations, Age >17, with CC Respiratory Infections & Inflammations, Age >17, without CC Simple Pneumonia & Pleurisy, Age >17, with CC Simple Pneumonia & Pleurisy, Age >17, without CC

Responses from physicians were generated on 11 charts through notes written on the prompter, which the physicians were specifically asked not to do. When this happened, the physician was asked to include the information in a progress note or discharge summary if applicable. Five charts had more specific types of pneumonia documented after the prompter form was placed, but the diagnosis codes still produced DRG 89. We were able to identify 8 charts where documentation following prompter placement lead to higher weighted DRG. Although we were able to increase revenue for those 8 cases, the small number of charts with a change to a higher DRG did not have a noticeable impact on the case-mix index. Findings When a specific organism was identified through sputum cultures, the physicians were good at documenting it (about 86 percent of the time). Physicians also documented aspiration pneumonia well. They documented it appropriately in about 80 percent of occurrences, although they noted only the causative organism in about 50 percent of those cases. For most cases coded to ICD-9-CM code 486unspecified pneumonia the sputum cultures did not provide any causative organism. Physicians were reluctant to document the type of infection that they suspected and treated the patient for it if there wasnt a positive culture. Other Studies Besides the pneumonia study, several other studies are ongoing. Data showing our CC rate on DRG pairs compared to the CC rates for other similar VHA hospitals was reviewed. Based on this data, we identified prostate procedures as an area where our severity and CC capture rate was lower than expected. We conducted a chart review and discovered that blood loss anemia and co-morbid conditions were not being documented clearly enough to be coded. We presented this data to the Urology Service with a good response and are now monitoring these charts for improved documentation. We found the same to be true for certain orthopedic and general surgery procedures and will be presenting that information in future service meetings. Challenges We identified several challenges that hindered our ability to get physicians to document clearly. Many of the challenges stem from physician lack of awareness of documentation requirements. There is a gap between the way a physician thinks, terminology used, and the information necessary for the coders to assign codes reflective of the care provided. Our challenges were both organizational and physician-related.

AHIMA Conference Proceedings, 2002

Organizational Challenges Limited Case Management Involvement With only one person reviewing charts, follow-up was not as complete as it could have been. Case managers were addressing both utilization review and discharge planning for their patient population. This did not allow time for them to assist with documentation review. Our Case Management department is being redesigned with clinical review and discharge planning functions. When this is complete, focused training of clinical review staff will prepare them to assist with documentation reviews. Identification of Patients Our current process involves reviewing a list of admissions from the previous day and identifying potential patients by admitting diagnosis. We expect that by using the clinical review staff, we will do a better job of identifying and reviewing patients. Limited Documentation Available Reviews can be ineffective until two to three days after admission. The history and physical may not be typed and on the chart for 24 to 48 hours, and cultures take days to produce results. In reviewing reports of pneumonia discharges from October 1, 2001 to December 31, 2001, we found information that helped narrow the review process (Appendix C). Overall, about 2/3 of patients had a stay of four days or more. In DRG 79, 92 percent of patient stays were four days or more. Nearly 70 percent of patients in DRG 89 stayed four days or more. Only in DRG 90, which represents simple pneumonia with no CCs, did the shorter stays outnumber the longer stays. To streamline review of pneumonia patients, we have requested a report that would identify patients still in house at four days and then review those patients who appear to be pneumonia patients. Since complex pneumonia patients generally have more than a three-day stay, this would eliminate 33 percent of the reviews currently being done; most of which end up in DRG 89/90 anyway (Appendix C). Physician-Related Challenges Physician Documentation Issues Post-coding chart reviews showed that physicians are reluctant to specify the type of organism they believe responsible for pneumonia unless cultures are positive. In many cases, antibiotic regimen was altered based on diagnostic work up and the response to treatment, but there is no reason noted for the change. Physicians dont understand that this is important information for coders. Response to Concurrent Prompters We had difficulty with prompter forms for two reasons. It was difficult to keep the form in a conspicuous place in the chart for the physician to review. Placing a flag with the physicians name on it helped call attention to it. However, providers were often unaware of or indifferent to prompters placed in the chart. When they did notice the form, they often wrote notes on the form itself, which would not become a permanent part of the medical record. The form was designed with no room for notes, but physicians still wrote notes or responses on the form. Any response at all was encouraging, but it was difficult to get physicians to rewrite those notes in the patient record.

AHIMA Conference Proceedings, 2002

What Works? Here are the tactics that we have found most effective in educating physicians about coding and documentation: Direct contact with physician One on one works best. Be succinct and to the point. Ask them specifically what you want to know or tell them exactly what they need to do differently. A physician advisor or liaison can help with some of those sticky situations when physician-to-physician communication is needed. Service meetings Attending regular service meetings armed with data on specific topics. We included comparison data, patient severity data, and audit results for our facility. Once that is presented, we instruct them on what they could do to more accurately reflect the condition of our patients in their documentation. Persistence Communicate, communicate, and communicate! Get your message out in any way you can. Be creative! Posters and contests give them a chance to think through a problem and apply the information you are sharing. Give the physicians a reason to care about what you are telling them. Be ready to answer the question What do I need to do differently? with a short, specific answer. Follow up and give praise when they do it right. Whats Ahead? Based on the findings from our first studies, we have devised the strategies described below. Condition-specific documentation tip sheets were created for providers, listing documentation requirements and tips. Examples include pneumonia and blood loss anemia (Appendix D). These are used during physician education sessions and will also be provided to the clinical review staff for reference. Condition-specific prompter forms for aspiration pneumonia, gram-negative pneumonia, and blood loss anemia have been developed (Appendix E) but have not been widely used yet. Clinical indicators for each condition are listed on the form for physician review. Provider education about prompter forms will increase awareness of the reason for prompter use including individual follow up education for providers when needed. A suggestion to create laminated, reusable prompters that wont allow the physician to write on them is being investigated. We will offer a pneumonia forum in fall 2002. This will be a panel discussion directed toward providers, case managers, nursing staff, and coders. The forum will discuss clinical issues, newest treatment options, documentation requirements, and coding issues. If we are successful with pneumonia, we will use this approach for other diagnoses. New physician documentation audits are being conducted to review documentation practices of all new providers. Documentation requirements are explained to each provider during an orientation session. The audit checks if they are following guidelines by selecting a random sample of charts to review items such as admission status, medical record requirements, utilization review elements, and documentation elements.

AHIMA Conference Proceedings, 2002

The results of the audit are reported to the physician either by letter or a face-to-face meeting, depending on the outcome of the audit. Surgical chart review is being conducted as a result of some missed CCs being discovered on Payment Error Prevention Program (PEPP) review. A 100 percent review of surgical charts without a CC was implemented to prevent this in the future. Improved access to data is in the works. Initially, each report of basic DRG data needed to be run through by a decision support analyst. Training is being scheduled to allow certain basic reports to be generated directly. In the future, it is expected that our office will be able to generate more complex reports independently, allowing greater and timely access to information. Conclusion At the time of this writing (April 2002), we feel that we have had some success. The main goals of our program were to educate physicians and improve documentation. We feel that we have definitely educated our physicians and that documentation has improved, although both of these are hard to measure. The first few months of our project were a learning experience for both our physicians and us. We hoped that our case-mix index would improve. Although we were not able to show a measurable increase in case mix through the pneumonia project, we did show an increase following one month of our surgical chart review (nearly 0.1 increase). At the time of writing, the second month of data is not available, so we are not able to say if that increase was sustained. Another expectation was an increase in our CC rates and severity level compared to the VHA group. Again, at the time of writing, the second quarter data were not available for review, so no comparison can be made. We were definitely able to show an increase in reimbursement through the improved documentation that resulted from prompters or discussions with physicians. Because we measure our financial impact manually at this point in time, it is difficult to give exact figures. Our best estimate was that we were able to capture approximately $100,000 of additional reimbursement in four months. There is no magic formula that will work at every facility. We are sharing what we have done and what is working for us. Each facility has to evaluate their own needs and prepare a plan to address those needs within the culture of its organization. By attending several seminars, listening to the presentations of several consulting groups, reading many articles, and acquiring our own experience, we have identified some common threads of successful documentation improvement programs. The keys to a successful program are administrative support; timely and accurate information; technology to gather, analyze, and present that information; and proper staffing to provide education and follow up in areas where improvement is necessary. As the title of our presentation indicates, the Documentation Improvement Program at LRMC is truly a work in progress, but we feel that we are making an impact. We hope this information is useful as you begin or continue this process at your facility.

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Appendix A
Original Pneumonia Prompter Form

CM/CODING USE ONLY: Date on Chart / Initials: Principal DX? DRG? Documentation after prompter placed? LEAVE THIS FORM ON CHART UNTIL IT GOES TO CODING
A diagnosis of pneumonia (R/O or possible) has been noted for this patient. If possible, specify if any of the following conditions apply to this patient by documenting in the medical record. DO NOT DOCUMENT ON THIS FORM AS IT WILL NOT REMAIN AS PART OF THE PERMANENT MEDICAL RECORD. Remember: coders cannot code from laboratory, radiology or other diagnostic reports.
Aspiration pneumonia Include supportive info such as: Pseudomonas pneumonia Pneumococcal pneumonia Pneumocystis pneumonia Staphylococcus pneumonia (includes MSRA) Unspecified gram negative bacterial pneumonia Viral pneumonia Other pneumonia (please be specific)

Risk Factors Swallow Study Results Witnessed Aspiration

E. coli pneumonia H. flu pneumonia Klebsiella pneumonia Mycoplasma pneumonia

**You may use PROBABLE/POSSIBLE when documenting an inpatient diagnosis

Questions? Contact Bobbi Tadwalt at Extension 2675.

Doctor

Patient Label

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Appendix B Pneumonia Study Results

Appendix C Summary of Discharges 10/1/2001 to 12/31/2001

330 128 102 70 4 0 59 7 32 8 2 68.6%* 3.9% 0% 57.8% 6.9% 31.4% 7.8% 2.0%

Unique charts reviewed Prompters placed on charts Prompters returned with charts DRG 79/80, 89/90 DRG 79 DRG 80 DRG 89 DRG 90 DRG other than 79/80, 89/90 DRG 76 or 475 Septicemia, pneumonia secondary Pneumonia ruled out Pneumonia secondary

Total Cases Assigned to DRG 79/80, 89/90 DRG 79 LOS 1-3 days LOS 4-35 days DRG 80 DRG 89 LOS 1-3 days LOS 4-41 days DRG 90 LOS 1-3 days LOS 4-9 days

232

25 2 23 0 179 54 125 28 20 8

10.8% 0.9% 9.9% 0% 77.2% 23.3% 58.9% 12.1% 8.6% 3.5%

Percentage is of total cases for 1st Quarter, FY 2002

16 6

15.7% 5.9%

*Percentage of prompters returned.

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Appendix D Blood Loss Anemia Documentation Tip Sheet

Blood Loss Anemia Acute: Document any intra-operative blood loss as less than expected, expected, or greater than expected. When blood products are ordered, indicate the reason in the order. Transfusion of blood products may prompt a query from the coder if there is a corresponding drop in lab values without clear physician documentation of the reason for transfusion. If blood loss is replaced and lab values dont demonstrate anemia, document the reason for replacement in operative report or in progress notes. Remember: A complication code for blood loss anemia will only be assigned if the physician indicates that the blood loss was excessive or due to a complication of a procedure. Simply documenting blood loss anemia following a procedure does not constitute a complication, but will create a higher level of severity for the patient stay.

If postoperative anemia is noted, but is documented by the physician as expected, a complication code will not be assigned. It will be coded to 285.1 acute posthemorrhagic anemia. If postoperative anemia is noted and physician documents that the blood loss was excessive or was due to a surgical complication, a complication code will be assigned. It will be coded to 998.1 hemorrhage or hematoma complicating a procedure. The code for acute posthemorrhagic anemia (285.1) may also be assigned if physician documentation indicates the anemia was due to the acute blood loss.

Chronic: If the anemia is due to a disease process, link the anemia to that disease process. If the anemia is due to a hematologic problem or use of anticoagulants, document the link to anemia. General Documentation Reminders: Coders cant derive codes from lab reports, radiology reports or reports from any other diagnostic testing. They may only code from physician documentation: H&P, orders, progress notes, consults and discharge summary. Discuss results of pertinent diagnostic testing in progress notes. For inpatients only, you may use probable, possible or suspected diagnoses if the treatment or testing is directed at that condition. Document additional conditions requiring evaluation, treatment, diagnostic procedures, increased monitoring or more intensive nursing care (Ex: insulin-dependent or uncontrolled diabetes mellitus, COPD, CHF, dehydration, malnutrition or electrolyte imbalances). To code these conditions, any treatment, evaluation, or monitoring must be documented by a physician and linked to the specific condition. Questions? Contact Bobbi Tadwalt (x2675) or Joy Jackson (x5962)

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Appendix E Aspiration Pneumonia Prompter Form

Doctor Your patient is demonstrating the following indicators CVA acute or previous Chronic liver disease Chronic alcoholism Dental caries / poor dentition / gum disease Impaired gag reflex Esophageal obstruction PEG / feeding tube Aspiration Pneumonia Query

for possible aspiration pneumonia: Dysphagia Decreased sensorium / LOC Coma OBS, dementia, severe Alzheimers History of aspiration Swallow study results Sputum culture consistent with possible aspiration pneumonia If aspiration pneumonia is suspected, please clearly document in progress notes and discharge summary. Positive cultures are not required for a possible/probable/suspected diagnosis. Please document the organism responsible for pneumonia (if known or suspected) in progress notes and discharge summary. Please document reason for change in antibiotic in progress notes and discharge summary. Please call with any questions. Thank you! Bobbi Tadwalt, RHIT Clinical Documentation Coordinator X2675

AHIMA Conference Proceedings, 2002