Health Information Management

Data gathering/reporting: One CDI specialist shares her hospital's methodology

CDI Strategies, October 16, 2008

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CDI specialists want to know what types of software other CDI departments use, what types of data they should be tracking, and how to gather it. Some CDI departments use sophisticated electronic health records while others rely on simple excel spreadsheets. Industry standards are tough to come by.

The CDI team at South Shore Hospital (SSH) in Weymouth, MA, has been tracking results of its program since March of 2001. The team concurrently reviews all DRG payer admits Monday through Friday, including those patients assigned to observation because they might be admitted as inpatients the following day.

The daily census for each of South Shore’s three full time CDI specialists varies from 50–85 patients each. The specialists start their day very early (4:30–5:30 a.m.), which allows the specialists to place a worksheet (and a query, if necessary) in the chart before a physician evaluates the patient that day.

"The data that we gather not only provides a strong reflection of our patient's severity of illness, but confirms the need for our CDI program," says Gail Marini MM, RN, CCS, manager of clinical documentation for SSH.

Prior to MS-DRGs, the program monitored Medicare-comparative ratios such as UTI/sepsis and CC/non-CC diagnoses. Every month it populated an Excel spreadsheet with the overall volumes of the hospital’s medical and surgical case mix. The database, maintained by the finance department, also included national and internal benchmarks and monthly/year-to-date totals. The information allowed the team to internally report trends, outcomes, and possible revenue opportunities for the CDI department.

Since the inception of MS-DRGs, however, South Shore had to change the Excel sheet for comparative ratios due to the new DRGs (i.e., with MCC, with CC, without CC or MCC).

However, Marini says that with a year of data under its belt the program will soon resume these comparative ratios.

"After October 1 we should be able to benchmark ourselves internally, locally, and nationally with one year of MS-DRG data," she says.

Along with using the Medicare Compare spreadsheet the department also tracks queries. The data on the query spreadsheet contains the following information: 

  • The account number
  • The clinical documentation specialist (CDS) who wrote the query
  • The current DRG
  • The documentation supported DRG
  • Payers and the revenue capture/loss (formulated)

At the end of the month, a CDS sorts the spreadsheet by those queries which impacted the final DRG, those that didn't impact the final DRG, and by query type. Sorting this spreadsheet allows the team to evaluate what diagnoses are prompting queries, and also whether a CDS needs to re-issue the query or revisit the physician or medical group.

The CDS places a concurrent worksheet with the DRG and any additional CC/MCC diagnoses in the physician progress section of the chart. After discharge (and pre-bill drop), if the DRG on the worksheet does not match the final coded DRG, if the chart is missing a worksheet, or if a physician doesn't answer the query, the team receives the chart for final review.

If the CDS identifies a clinical or coding reason why the final DRG differs from the coded DRG, the CDS fills out a validation worksheet, communicates this with the coder, and places the final result on a spreadsheet.

Finally, a CDS places the captured and lost opportunity revenue from the query database and the validation database on a fiscal year spreadsheet, which is broken out by months.

South Shore's CDI department occasionally formulates additional spreadsheets to track targeted DRGs, physician responses, mortality, and other measures.

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