The University of Toledo Medical Center collected $1.4 million in gross revenue last fiscal year because of a commitment to educate on accurate and detailed physician documentation.
Paula Kessler, director of health information management at UTMC, said the documentation improvement team is dedicated to the identification of clinical indications and treatments or services provided to patients. The team wants to make sure the treatments are reflected accurately in the physician’s documentation in the medical record before going to the inpatient coders and, ultimately, the insurance companies. The more accurate the coding, the more likely the insurance companies will pay accordingly, she said.
“The bottom line is we are doing a good job of painting an accurate picture of the patient’s hospital stay, which allows for the hospital to be accurately reimbursed for the services provided,” Kessler said.
UTMC began hiring documentation improvement specialists in 2007. Kessler said housing the documentation improvement program in health information management works because of the detailed and concentrated coding education and training that the employees receive in a two- or four-year health information college program.
For instance, a doctor might note a drop in hemoglobin and order a transfusion. However, the doctor might never state that the patient has anemia and what type of anemia the patient has, which is important to know for reimbursement purposes.
“Documentation improvement specialists know the coding and are diligent in their efforts to contact the doctors to get clarification,” said Holly Hill, coding manager. “We don’t want to leave money on the table. This is what we went to school for. Doctors went to school to care for patients. We are here to help the doctors.”