Effective October 1, 2007, the Centers for Medicare and Medicaid Services (CMS) adopted the Medicare Severity Diagnosis Related Groups (MS-DRG) system as the basis for Medicare reimbursement to providers. Payment for inpatient care is now based on severity of illness. Two hundred seven new diagnostic codes for complications and/or co-morbidities (CCs) and major complications and/or co-morbidities (MCCs) were created.

Stony Brook University Medical Center recognized the need to improve clinical documentation of patients’ conditions and treatments in order to appropriately bill using the MS-DRG codes. The Care Management Department created a team of four RN Clinical Documentation Specialists (CDS). Their goal is to ensure comprehensive documentation is reflective of patients’ severity of illness, using language that allows coders to assign the most appropriate codes and modifiers. Outcomes include increased Case Mix Index (CMI), appropriate length of stay, and improved observed-to-expected mortality and morbidity ratios.

Navigant, a consulting firm, was hired to launch an extensive documentation improvement program that included training of the Clinical Documentation Specialists, as well as Coders, Physicians, Nurse Practitioners and Physician Assistants. Additionally, Case Managers introduced the CDS to Case Management processes and procedures.

The CDS’s focus is on concurrent chart review of patients with Medicare. Using software from 3M and Navigant, they enter data from the reviewed charts, assign an initial and working DRG, and generate queries to clarify severity of illness. They also track physician response, the potential impact on CMI, and financial return. Once the patient is discharged, the coders assign a coding DRG, follow up unanswered queries, and enter the final DRG into the database.

Using a shared file and retro chart review, the CDS reconciles the final DRG code with their expected DRG. DRG mismatches are then reviewed weekly at a joint Health Information Management (HIM)-CDS Task Force Meeting where final determinations are made. Financial review comparing “expected” to “actual” reimbursement is done quarterly.

The impact of the program has been substantial. In the first 6 months, an increase in revenue generated was verified, as was an increase in CMI and appropriate length of stay for the Medicare Group.