Big Bucks in Clinical Documentation

A clinical documentation program that focuses on patients who are to be admitted from the emergency department at Wishard Health Services in Indianapolis seems like a small, unimportant change, but instead, it has big implications for a hospital's case mix index and thus its reimbursement, says Isaac J. Myers II, MD, Wishard's vice president for clinical and business integration.

That's because the change has a direct positive effect on care coordination and process integration and should help not only with improving patient care, but also with making sure the hospital is being paid correctly for the severity of illness of the patients it's admitting.

"The language the physicians use and the language the coders use is very different," says Myers, a family physician who, among his previous jobs, was a vice president of a health plan. And since the language the coders use is the same one payers use, this time, they win. "It wasn't that the old system [in which documentation was reconciled outside the ED] was incorrect," says Myers, "but when it came to coders, they needed certain things that weren't taught to physicians."

For example, physicians aren't always thinking about whether congestive heart failure patients' blood pressure readings are systolic or diastolic, but it's important for clinical documentation and affects how the hospital can code on the patient's record. Another example occurs when a surgeon's patient might experience acute blood loss during an operation. "You may have surgeons avoiding that because they think they'll get dinged for it," Myers says. "But that documentation can impact the level of acuity and thus the level of reimbursement."

Myers got help implementing the program, which began in 2009, from Atlanta consulting firm J.A. Thomas. At the time, Wishard was running a case-mix index in the neighborhood of 1.53 and, through reconciling clinical documentation from the ED through discharge, predicted it could improve that score by at least 5%.

"For every point that your case-mix index improves, say from 0.53 to 0.54—that could be a couple hundred thousand dollars," Myers says. Since the program started, Wishard's case-mix index has improved to 1.65 on average, he adds.

"This helps minimize risk," he says, adding, "doctors have really embraced the education tied to clinical improvement."

Every time Wishard, a teaching hospital affiliated with the residency program at Indiana University, gets new residents, clinical documentation specialists meet with the team. They've created pocket cards of common terms used by physicians to benefit the coding process for each service line.

"This has become part of the culture and the expectation."

—Philip Betbeze