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Clinical Documentation Improvement Team. PRESENTED BY: Marty McNabb, MSN, RN. DATE: April 23, 2010. Introduction . Saint Mary’s Clinical Documentation Improvement Program (CDIP)

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clinical documentation improvement team

Clinical Documentation Improvement Team


Marty McNabb, MSN, RN


April 23, 2010

  • Saint Mary’s Clinical Documentation Improvement Program (CDIP)
    • “An integrated program to improve the accuracy, specificity and completeness of clinical documentation through education, assessment, review, communication, clarification, querying and analysis of clinical documentation patterns involving CHW Health Information Management Coders, Coding Documentation Specialists, RN Case Managers and RN Clinical Documentation Specialists” (Catholic HealthCare West administration Policy and Procedure-Concurrent Clinical Documentation Improvement Program-Clarification Form Usage).
  • Clinical Documentation Improvement Program (CDIP) started in April 2008
  • 1.5 Clinical Documentation Improvement Specialists (CDIS)
    • One CDIS for 2,000 Medicare Discharges
    • CDIS report to the Director of Case Management
  • Initial Education
    • CHW contracted with PricewaterhouseCoopers Clinical Consultants (PwC)
    • 2 days of classroom instruction CDIS
    • HIM Coding Professionals also attended the classroom instruction
    • CDIS practiced with PricewaterhouseCoopers Clinical Consultants on the units doing concurrent chart reviews for 1.5 weeks
  • Follow-up education
    • PricewaterhouseCoopers provides follow up on-site visits for CDIS.
      • PwC has returned three times since implementation
    • Monthly phone conferences with all CDIS together to discuss issues and provide education on topics requested by CDIS
      • Utilizing nursing and ancillary documentation to clarify for Functional Quadriplegia and Coma
      • ICD-10
chart review by cdis
Chart Review by CDIS
  • All DRG payers – All charts reviewed within 48 hours of admit
    • Medicare – First Priority
    • Senior Dimensions, Senior Care Plus, Secure Horizons
    • Health First
  • Daily follow-up on charts that have written clarifications
chart review by cdis7
Chart Review by CDIS
  • Long term goal is to review all charts
  • Goal of chart review
    • “Assess the accuracy,specificity and completeness of physician clinical documentation and to identify if clinical findings suggest the presence of other conditions that are not explicitly documented” (Catholic HealthCare West administration Policy and Procedure-Concurrent Clinical Documentation Improvement Program-Clarification Form Usage).
clarification process
Clarification Process
  • CDIS clarify
  • HIM Coding Professionals query
  • Clarification Process
    • Verbal and written clarifications are used
    • “Verbal communication is the preferred method of communication with physicians because it provides for clarification of intent and feedback”(Catholic HealthCare West administration Policy and Procedure-Concurrent Clinical Documentation Improvement Program-Clarification Form Usage).
clarification process verbal
Clarification Process - Verbal
  • Benefits of Verbal Clarification
    • Immediate feedback from the physician/provider
    • Questions from CDIS and physician/provider answered during the course of the conversation
    • Immediate education for the physician
  • Challenges of Verbal Clarification
    • Physician/provider may not like rounding interrupted with additional questions
    • Physician/provider may push back and feel that his/her practice of medicine is being questioned
clarification process written
Clarification Process - Written
  • CDIS use corporate coding compliance generated progress notes and clarification forms
  • Written clarification forms include the following clinical information
    • Signs/symptoms
    • Abnormal lab values
    • Results of diagnostic tests or procedures
    • Assessments of RNs or other licensed health care professionals that may indicate the need for further physician clarification, specificity or documentation (Catholic HealthCare West administration Policy and Procedure-Concurrent Clinical Documentation Improvement Program-Clarification Form Usage).
  • Goal is to provide the MD with all clinical information to answer the clarification without having to increase rounding time by looking for information in the paper or electronic chart.
clarification process written11
Clarification Process - Written
  • 56 Written Clarifications in use
    • Lab Results Associated with Blood Loss
    • Present on Admission
    • Pneumonia Specificity
    • Infectious Disease
    • Urosepsis
    • Impaired Gas Exchange
    • Diabetes Mellitus
    • Chest Pain
    • Syncope/Near Syncope
    • Impaired Renal Function
    • Lab Results Associated with Neoplastic Disease
clarification process written12
Clarification Process Written
  • Written Clarifications in use (Cont.)
    • Brain Imaging Results-Clinical Significance of Mass Effect
    • Drug/Substance Use
    • Hypertension
    • Impaired Gastrointestinal Function: Bleeding Pulmonary Infiltrate
    • Seizure
physician provider education
Physician/Provider Education
  • Physician/Provider education is an important aspect to the success of our program
  • Physician/Provider education opportunities:
    • New physician/Provider orientation
    • Section meetings
    • Hospitalists Meetings
    • Verbal clarification process
    • Offices visits when completing retrospective clarifications
    • Posters in Physician Lounges
    • Printed education
    • Pocket education guides
other documentation improvement education
Other Documentation Improvement Education
  • RN staff education at departmental meetings
      • Purpose of the Documentation Improvement Program
      • POA/HAC
  • Registered Dietitian education – documentation of degree of malnutrition
  • Physical Therapist education – documentation of excisional and non-excisional debridement
cdis and him coding professionals meetings
CDIS and HIM Coding Professionals Meetings
  • First Meeting – April 24, 2008
    • Reviewed Physician letter announcing program start
    • Identified the top 4 retrospective queries being done by HIM Coding Professionals
      • These became the priority clarifications by the CDIS
      • The number of retrospective clarifications done by the CDIS decreased by 75%
cdis and him coding professionals meetings16
CDIS and HIM Coding Professionals Meetings
  • Examples of content discussed at meetings
    • Retrospective clarification issues
    • Statistic review
      • Monthly Case Mix Index
      • Number of concurrent chart reviews/clarifications placed by CDIS
      • Types of concurrent clarifications
cdis and him coding professionals meetings17
CDIS and HIM Coding Professionals Meetings
  • Education updates
    • Coding Clinics
    • Chart reviews to determine clinical indicators for clarifications
      • Encephalopathy
      • Sepsis
  • Survey results
    • Corporate Coding Compliance
    • PricewaterhouseCoopers
  • Clinical Documentation Improvement Projects
clinical documentation improvement projects
Clinical Documentation Improvement Projects
  • BMI documentation for coding
    • CDIS met with Clinical Automation Department
      • BMI calculation was placed on electronic admit form
      • BMI calculated at the time the patient became and inpatient (not from the ED height/weight)
      • BMI pulled to the computer generated MD progress note
clinical documentation improvement projects19
Clinical Documentation Improvement Projects
  • CDIS meet daily with the RDs
    • Discuss patients and determine who is malnourished and to what degree
    • CDIS clarify with MD based on the RD assessment
    • Communicate with HIM Coding Professionals how RD assesses malnutrition
clinical documentation improvement projects20
Clinical Documentation Improvement Projects
  • CKD staging
    • CDIS met with Cerner lab analysts to determine feasibility of displaying the eGFR on the lab tab in PowerChart.
    • Once this was done CDIS did education with MDs regarding where the eGFR could be found when clarifications were placed for CKD staging.
clinical documentation improvement projects21
Clinical Documentation Improvement Projects
  • GI bleed preprinted orders and on line care sets
    • CDIS met with MD to evaluate some changes to the transfusion orders on the GI bleed orders
    • Transfusion orders now indicate the reason for transfusion-acute blood loss anemia, acute on chronic blood loss anemia and chronic blood loss anemia
clinical documentation improvement projects22
Clinical Documentation Improvement Projects
  • Emergency Department Physician Documentation Tools
    • CDIS and HIM Coding Professionals reviewed templates to identify POA capture issues
    • CDIS worked with company providing templates to make customizations to assist in POA capture
clinical documentation improvement projects23
Clinical Documentation Improvement Projects
  • Next on the horizon
    • Automation of Clarification forms
    • Clarifications will go electronically to the MD inbox for response
cdip benefits for him coding professionals
CDIP benefits for HIM Coding Professionals
  • Decrease delays and re-work resulting from post-discharge questions to MD about clinical documentation(Catholic HealthCare West administration Policy and Procedure-Concurrent Clinical Documentation Improvement Program-Clarification Form Usage).
    • HIM Coding Professionals have less retrospective queries to do with CDIS doing concurrent clarifications
cdip benefits to the organization
CDIP benefits to the organization
  • Improve the accuracy of the hospital’s Case Mix Index (CMI)
  • Bill drop is not delayed

(Catholic HealthCare West administration Policy and Procedure-Concurrent Clinical Documentation Improvement Program-Clarification Form Usage).

cdip benefits for our patients
CDIP benefits for our patients
  • Capture appropriate clinical findings or conditions so that appropriate treatment is provided to patients.
  • Assure that services provided are warranted by the patient’s actual and documented clinical condition.

(Catholic HealthCare West administration Policy and Procedure-Concurrent Clinical Documentation Improvement Program-Clarification Form Usage).

challenges along the way
Challenges along the way
  • Physician resistance
  • CDIS need to learn to communicate and work in a new world that changes frequently
  • What has helped us develop a successful Clinical Documentation Improvement Program
    • Initial education and continued follow-up support and education
    • Positive working relationship that we have with our HIM Coding Professionals.