Case study: The University of Tennessee Medical Center at Knoxville Martha Collins, BSN, RN Trey La Charité, MD Lisa Peterson, BS, RHIA Carla Stump, BS, RHIT, CCS

UTMCK CDI project results 2007 2008 Overall CMI 1.721 1.938 Medical CMI 1.087 1.249 Surgical CMI 2.620 2.938 Overall CC capture rate 26.9% 23.6% Medical CC capture rate 28.4% 25.5% Surgical CC capture rate 24.7% 21.6% Overall MCC capture rate 22.6% 34.1% Medical MCC capture rate 42.0% Surgical MCC capture rate 17.1% 23.4%

Background Knoxville: University of Tennessee Medical Center: Metropolitan area of 350K people 8 hospitals, five health systems—all competing for patients University of Tennessee Medical Center: 450-bed academic medical center Level-1 trauma center 12 residency programs 3 fellowships

Program model UTMCK administration recognized need for improved physician documentation: Previous “DRG - Documentation” program with case management/coding demonstrated limited success Selection of vendor for program initiation: One chosen from four solicited bids Targeted payers selected: DRG payers starting with traditional Medicare Expansion to other payers over time

Program model Created in medical records department, as opposed to extension of case management department: Three RNs added to medical records department for additional concurrent physician interaction CDS nurses responsible for chart review to establish and update concurrent DRGs Chart reviewers have only one responsibility, as opposed to having to add one more thing to an already demanding job

Program model CDI core team members: Reports to MR director and CFO Medical records manager Coding quality coordinator Clinical documentation specialists (CDS): Interviewed and selected three RNs with extensive clinical experience to serve as concurrent, inpatient chart reviewers Inpatient UTMCK coders Physician advisor: Chosen from active medical staff Reports to MR director and CFO

Initial education and training Vendor provided RN that trained: Newly hired RNs Inpatient coders Medical records manager Coding quality coordinator RN lawyer from compliance department Visits to the group by senior hospital management Visits to the group by newly hired physician advisor

Initial education and training Extensive training commitment by facility In-depth review of: Pathophysiology of disease processes DRG families that matched the disease processes Common laboratory results and their significance Education on coding guidelines Lecture format with clinical, case-based discussions Done at hospital as soon as all three CDS nurses were hired

January 2008—Go live Medical records manager introduced CDI program to nursing administration CDS nurses assigned to specific areas in hospital to promote continuity CDS nurses made individual introductions to their assigned patient care areas CDS nurses received laptop computers with: Hospital clinical information systems Coding system CDI database CDS nurses received current coding books

January 2008—Go live CDS nurse record review From the RN perspective Establish our working principal diagnosis Establish working DRG Update working DRG based on information obtained during concurrent chart reviews

Physician queries Based on clinical facts documented in the medical record Written and placed in front of the last progress note in the chart CDS nurse checks daily for query response Disagreed or unanswered queries are presented to physician advisor

DRG mismatches Occur when coder’s DRG does not match the CDS nurse’s working DRG Coding quality coordinator is notified of DRG mismatch CDS nurse reviews the DRG mismatch Final decision rests with the coding quality coordinator

Coding quality coordinator role Ensures compliance with CMS, AHA, AHIMA inpatient coding guidelines CDI core team education regarding inpatient coding guidelines Serves as liaison between CDS nurses and inpatient coders Oversight of DRG “mismatch” resolution Serves as “sounding board” for new ideas to encourage compliance with CDI goals

Role of inpatient coders Program designed to have minimum impact on coding productivity Ongoing CDS nurse education through sharing of coding expertise Participation in DRG “mismatch” resolution process Post-discharge physician query formulation if concurrent, inpatient physician query remains unanswered

Role of physician advisor Provides physician education regarding opportunities for documentation improvement “Championing” to the medical staff the significance and ramifications of documentation improvement Physician intervention when compliance with or responses to physician queries are not satisfactory Development of new conduits to encourage medical staff compliance

Physician education Service line–specific CDI presentations: Tailor significance and ramifications of CDI project to their unique concerns Introduction of CDS nurses at presentations Development and distribution to all medical staff of “universal” CDI pocket reference card: Medical staff all have same language requests, avoiding confusion and promoting unity

Physician education Education of all incoming interns before starting on wards July 1, regardless of service line: Proper record “formatting” presentation: What is expected in a written/dictated H&P, a progress note, a discharge summary, and a procedure note Full CDI presentation with CDI pocket card distribution Introduction of CDS nurses to residents

Physician education Institution of service line–specific CDI “blitzes”: Identify specific service line, with opportunities for documentation improvement and review every chart on that service that day: Leave physician queries as needed Take CDI core team to lunch in physicians’ lounge: Occupy prominent table Display CDI poster Distribute CDI pocket cards, as needed Answer questions

Physician education Active participation with development of computerized documentation programs to ensure CDI goals realized: Anesthesia department purchased and customized program for improved data gathering for preoperative clinic Trauma service developing new electronic daily progress note generator and data collection system Continued physician education efforts: Additional service line–specific CDI presentations Quarterly medical staff reviews and updates

Role of medical records manager Provides oversight and direction of CDS nurses and inpatient coders Facilitates the coordination and inclusion of CDI project goals within other departmental and committee agendas Tracks and reports CDI project performance results Serves as liaison between the CDI project and UTMCK administration

Program maintenance Monthly CDI dashboard review: Monitor CDI project results: Review overall and service line–specific CMIs, CC, and MCC capture rates, MS-DRG–specific mortality rates, etc. Identification of service lines with continued opportunities for documentation improvement: Is that service line in need of being “blitzed?” Benchmark DRG pairs and audit for compliance

Program maintenance Weekly CDI core team meetings: Brainstorming session for idea generation, drawing on experiences of CDS nurses Everyone on first name basis, with equal weight at the discussion table Physician query review with physician advisor Senior management continues to visit periodically, showing continued support and appreciation of our efforts and to review our impact Maintain forward momentum of CDI project

Program maintenance Continuous education through: Coders and coding quality coordinator Physician advisor Yearly coding update from local professional organization ACDIS conference calls Attending annual ACDIS conference

UTMCK CDI Project Results 2007 2008 Overall CMI 1.721 1.938 Medical CMI 1.087 1.249 Surgical CMI 2.620 2.938 Overall CC capture rate 26.9% 23.6% Medical CC capture rate 28.4% 25.5% Surgical CC capture rate 24.7% 21.6% Overall MCC capture rate 22.6% 34.1% Medical MCC capture rate 42.0% Surgical MCC capture rate 17.1% 23.4%

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