Documentation improvements boost coding performance

Hospitals will lose money under MS-DRGs, unless they implement documentation improvement programs that include coders, clinicians, case managers and any other staff that documents care delivery. This statement is taken from an article by Janis K. Oppelt, "Improving Documentation for Better Coding," published in the April 7, 2008 issue of Advance for Health Information Professionals.

According to the article, documentation-improvement programs should include the following elements:

• Explain the payment puzzle to all parties involved in the revenue-cycle process, since many of the staff members do not understand how documentation and coding impact reimbursement.
• Recruit a physician or team of physicians to help educate medical and nursing staff about MS-DRGs and documentation.
• Show examples of inadequate documentation and illustrate how it can be transformed into comprehensive documentation. Use that documentation to show how coding is assigned.
• Encourage physicians to communicate with non-medical professionals (i.e., coders, etc.), and also work with physicians to teach them how to communicate constructively.