The implementation of MS-DRGs effective October 1, 2007,  expanded the number of DRGs from 538 to 745, increasing the importance of accurate and thorough clinical documentation. Major revisions to the Complication/Comorbidities (CC) list occurred, resulting in three groups of severity rather than two: 

  1. Major CC (highest level of severity)
  2. CC (moderate level of severity)
  3. Non CC (severity of illness not considered significant enough to impact DRG) 

Accurate and thorough clinical documentation that is properly coded and billed to payers results in the following benefits to both the hospital and medical staff: 

  1. Increased third party billing compliance under programs such as RACs,
  2. Improved quality reporting as consumer-driven healthcare and need for greater transparency increases (e.g., Health Grades), and
  3. Increased revenues by coding the most appropriate DRG and minimizing denials. 

In recognition of these considerations, we implemented a clinical documentation initiative. We hired clinical documentation specialists (CDS), as well as RNs with experience in utilization management and coding. We worked with an outside vendor, Med Assets, who provided some consultative services but most importantly license a decision-support system that integrates with our utilization management system. We began the process by providing in-services at both leadership and medical staff meetings and then followed-up with individual meetings with key physicians. The CDSs perform admission reviews of all assigned patients using clinical documentation guidelines and CMS coding guidelines. This ensures that the documentation by the physician captures all diagnosis/conditions for the patient reflected in the documentation of the medical record. CDSs track all cases reviewed, noting physician queries and responses, and enter information into the MDX decision support system.

The program was implemented in 2008 and we have realized all the benefits anticipated.  The program is monitored on a regular basis.  Report cards are published biweekly and shared with the Medical Records Committee and hospital leadership.   

Ray Lefton, CPA
Vice President, Finance
Princeton HealthCare System

Publication Date: Wednesday, April 14, 2010