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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. Nurses are vital to this effort.
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 reviewing clinical documentation for Medicare patients before it goes to medical coders. The nurses work with physicians, residents and physician assistants to ask clarifying questions about the patients’ conditions to ensure that documentation is thorough before submission.
“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.”
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 coordinates with medical staff to provide education and increase awareness about the need for comprehensive quality medical record documentation. As 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 is crucial to CDI’s effectiveness,” said Kelly. “They review and relay the complexities of patients’ medical data.”
Clinical documentation specialist Cathy Farraher, RN, BSN, MBA, CCM, is one of these nurses. She joined the CDI program team last February.
“Our goal is to capture, as accurately as possible, the severity of illness in the patients we treat, as well as their use of resources,” said Farraher, who has worked at BWH for nearly a decade. “This impacts the diagnosis-related group (DRG), which in turn impacts length of stay, quality indicators and other factors that Medicare tracks. Many physicians here are interested in improving documentation related to this, and it’s been going pretty well.”
Documentation specialist Ellen Downing, RN, CPHM, is also part of the CDI program team. Like Farraher, Downing reviews medical documentation for clarity and specificity to better reflect the “acuity of stay, intensity of service and severity of illness,” she said. She and the other nurses on the team meet frequently with coders to discuss problems that arise.
“Hospital leadership is really taking this on and communicating the importance of the program, which, if successful, will allow the institution to continue to provide quality care services and be reimbursed for those services,” Downing said.