Assessing the appropriate level of care for our patients is a critical component of delivering high-quality and well-documented health care for patients in our hospitals. In early 2022, the number of patients in observation at our hospitals was high, and some were staying in observation much longer than needed for their condition—sometimes up to 10 days. In addition, many of these patients were already receiving an inpatient level of care while in observation, a discrepancy that led to a loss of reimbursement and a high percentage of denials from payors.
This sparked our Health Information Management (HIM) team to take a different approach to improve clinical documentation and quality reporting. In the fall of 2022, Mullica Hill and Vineland introduced clinical documentation improvement (CDI) physician reviewers to daily patient rounds. These specialists are certified in both CDI and medical coding.
“The purpose of these CDI physician specialists is to round with attendings and see if observation patients meet the criteria to be moved to inpatient care,” said Jaymica Patel, M.D., chief medical officer for Inspira’s Mullica Hill and Woodbury campuses. “These specialists are augmenting the current care team by looking at clinical documentation, services being provided and patient presentation to craft a more complete and accurate patient story.” In short, CDI specialists are helping to ensure our patients are being classified appropriately, based on their medical needs.
Mullica Hill and Vineland have already seen the compelling results of this new program. In the first half of 2022, an average of 20 percent of patients admitted to observation were converted to inpatients. Now, an average of 30 percent of observation patients are converted to inpatients. Our hospitals are also facing fewer denials from insurance payors and making medical decisions at a much quicker pace. “This program has given physicians more tools to make decisions, record fuller documentation and be accepted by payors,” said Dr. Patel.
As a result, not only have we improved clinical documentation and decision-making, but we’ve also given our patients a higher quality of care. “Patients are getting the care they need based on the severity of their presentation,” said Dr. Patel. “In addition, physicians are able to document patient conditions with more precision and clarity, which will lead to a better continuum of care down the line, especially if the patient visits another health system.”
Better reporting also means capturing a more accurate physician profile and providing a learning experience when it comes to recording patient presentations and conditions. “By adding CDI specialists to an already complex and collaborative team, we’ve seen that attendings are writing more specific reports of patient diagnoses and having more conversations among the team about what the patient needs,” said Dr. Patel.
If you have questions about Inspira’s CDI physician specialists or our HIM program, please contact Cecilia G. Hilerio, M.H.A., R.H.I.T., assistant vice president of Health Information Management and
Clinical Documentation Improvement, at hilerioc@ihn.org.
