Clinical Documentation Improvement Moving Forward

Matthew Vitale, MD

One of the most basic, yet essential ways BWH and BWFH are working to meet their patient affordability goals is to ensure that the hospitals are reimbursed correctly for patient care. It sounds simple, but there are many complexities in the clinical documentation process that can prevent the hospitals, their clinics and diagnostic and procedural areas from receiving adequate reimbursement.

Hospitals are paid a single, predetermined sum based on a patient's diagnosis-related group (DRG). A medical coder analyzes the clinical statements related to a patient's care and assigns standard codes using the DRG classification system to submit payment requests.  

If certain boxes on the clinical forms are overlooked, it could cost the hospital thousands of dollars in reimbursement. Coders, who don't have clinical training, rely on physicians to thoroughly and accurately complete the documentation. 

"The documentation must be accurate and detailed so that a coder can code properly," said Sharon Vitti, vice president of Women's Health and Ambulatory Services and executive sponsor of the CDI program. "Making sure our documentation is as complete as possible is also essential to patient care; it strengthens hand-off communications and outcomes data that we collect."

Under the Patient Affordability umbrella in the hospitals' strategic commitments, BWH and BWFH have put in place a Clinical Documentation Improvement (CDI) program to ensure documentation is accurate. At the hospitals, eight nurses are responsible for augmenting the coding process by reviewing clinical documentation for Medicare patients before it goes to medical coders. The nurses work with physicians and residents to ask the right questions about the patients' conditions to ensure that documentation is thorough before submission.

"For example, if you check ‘pneumonia' in the documentation, but you leave out critical information about other conditions we are treating the patient for, that can cost us about $30,000 to $40,000 that otherwise would have been reimbursed," said Vitti. "That is significant. We now go through this process for every Medicare patient who receives care here."

Though documentation improvement has been ongoing for more than 10 years, it was redesigned and reintroduced as the CDI program in October 2011. In early 2012, Matthew Vitale, MD, and Andrea Kelly, JD, RN, were appointed medical director and program director, respectively, to lead and oversee the efforts.

Vitale, who is associate director of the BWH Hospitalist Service, coordinates with medical staff to provide education and increase awareness about the need for comprehensive quality medical record documentation. He also provides clinical guidance and support to non-medical staff as part of the role.

"I try to think about the questions I would have looking at a patient's medical chart from a coder's perspective," said Vitale. "In terms of the bigger picture, I speak with physicians about what this program is and how it ties into the clinical work they're doing."

"We provide very high quality clinical care here, and sometimes documentation tasks are harder for people to get excited about," Vitale added. "But so much builds off of the documentation we produce, so I want to educate physicians about Medicare-specific language and support them in their practice. The goal is to capture who our patients are, and to do that, we have to use the right words and check the right boxes."

As CDI program director, Kelly provides daily oversight of the CDI team of nurses at BWH and BWFH, ensuring accurate and timely clinical documentation in the medical record.

 "The insight of our nurses, who review and relay the complexities of patients' medical date, is crucial to CDI's effectiveness," she said. "We hope to keep moving forward and sharing the program's goals with care providers."