2. 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

3. 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%

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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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%

27. Questions?