DRG/Clinical Documentation

The client.

A 700-bed academic medical center in the Northeast.

The business issue.

Due to inadequate documentation of medical records, this medical center experienced lost revenue, inaccurate quality rating scores (severity of illness and risk of mortality), and lost opportunities to improve compliance with CMS rules and regulations.

The solution.

Claro Group professionals completed an assessment of the center's documentation procedures, including a statistically valid medical record review. This process revealed an opportunity to improve documentation through a concurrent review process that would result in:

• More than $2 million in additional net revenue for Medicare alone.
• A five-percent increase in severity of illness.
• A 25-plus percent improvement in mortality outcome scores.
• Improved compliance with CMS rules and regulations.

The project team utilized a proven concurrent review process – one implemented at hundreds of hospitals throughout the country – designed to clarify documentation in the medical record during the patient stay. This included:

• Integrating clinical documentation specialist roles into existing case management responsibilities.
• Educating case managers and inpatient coders to ensure effective implementation of the concurrent review process.
• Educating medical staff related to the benefits of complete and accurate documentation, severity of illness and risk of mortality profiling, and the role of the medical staff in the new process.
• Developing a new policy and infrastructure supported by the necessary tools and education for long-term success.
• Implementating extensive monitoring and measurement tools to facilitate ongoing management of the program and the sustainability of results.

The results.

This approach enabled the medical center to generate additional Medicare net revenue of over $2.5 million in the first year by improving documentation in the medical record. In addition, it experienced dramatic improvement in key quality indicators (severity of illness and risk of mortality), both for the health system and across physician specialties.

In addition, it has been able to sustain these results through post-implementation monitoring and measurement of case mix index, DRG pair ratios, operational performance indicators, quality ratings measures, and compliance metrics.