Boosting Reimbursement Through Clinical Documentation Improvement

Case Study

Boosting Reimbursement Through Clinical Documentation Improvement

The Challenge

A 43-bed rural Illinois community hospital, serving a large Medicare population, faced financial strain exacerbated by the ICD-10 transition. The hospital’s clinical documentation metrics, particularly CC (complication comorbidity) and MCC (major complication and comorbidity) capture rates, lagged at the bottom of regional and national benchmarks. This led to a 20th percentile payment per case for short-term acute care, well below peers, causing significant reimbursement disparities. Poor CC/MCC capture failed to reflect patient complexity, reducing Medicare reimbursements and skewing quality metrics like Case Mix Index (CMI) and mortality rates.

The Solution

IN Compass Health partnered with hospital leadership to launch a physician-led Clinical Documentation Improvement (CDI) Program targeting the top 20 Diagnosis-Related Groups (DRGs). The program aimed to enhance documentation accuracy, optimize coding, and align reimbursements with services provided, while preparing for potential audits.

Key Initiatives:

Multidisciplinary Team: Physicians, clinicians, health information management, and revenue cycle managers collaborated to improve communication and coding accuracy.
Comprehensive Education: Monthly training sessions, led by physicians, included on-site presentations and online case studies, focusing on best practices, problematic DRGs, and CDI orientation for all staff.
Targeted Feedback: Physician chart audits compared actual versus ideal documentation, resonating with hospitalists by aligning with their clinical experience.

The Result

The CDI program significantly improved documentation accuracy and financial outcomes, ensuring appropriate reimbursement and sustained performance:

68% improvement in clinical documentation within 90 days.

70% of cases accurately captured CC or MCC within 12 months.

61% increase in payment per case within 12 months, reaching 95% by 24 months.

CC/MCC capture rate sustained above 69% after 36 months

Conclusion

The CDI program transformed the hospital’s financial and operational performance by aligning documentation with patient complexity. Enhanced CC/MCC capture rates boosted reimbursements, improved quality metrics, and fortified audit readiness, demonstrating the value of physician-led, collaborative initiatives in rural healthcare settings.