Q&A: NICU audits and reviews

CDI Strategies - Volume 14, Issue 22

Q: We’re considering doing a chart audit of our neonatal intensive care unit (NICU) but aren’t sure what the value of that would be. Do you have experience auditing your NICU charts? If so, what did you find?

A: “We recently received a Vizient report that showed our neonatal population (DRG 790) tend to have a higher length of stay (LOS), and therefore cost, compared to cohorts,” says Dawn Diven, BSN, RN, CCDS, CDIP, CCDS-O, enterprise system director of CDI at WVU Medicine in Morgantown, West Virginia. “We have done a DRG drilldown looking for potential documentation issues but are not finding any significant trends.”

Initially, they were concerned it was due to under documenting and under coding neonatal abstinence syndrome babies, but their audits haven’t been able to verify that assumption yet.

“We review Level 3 NICU—mostly at our academic teaching facility,” says Joy Coletti, MBA, RN, CCDS, system services director of CDI at Memorial Hermann Health System in Houston, Texas. “This was based on a small audit we did internally about two years ago that suggested most of the documentation opportunity was within this Level 3 NICU level population.” 

“Our ongoing record review and reconciliation process also found correct coding opportunities, especially with accurate birth weight coding,” Coletti says. “Additionally, our NICU audits have uncovered some errors in level placement, which has a significant impact on the cost of care provided.”

The CDI team at New York-Presbyterian Hospital in New York City also reviews NICU records, Jerilyn Loria, MBA, RHIA, CDIP, CCS, director of clinical documentation, adds. A few of the diagnoses they look for include:

  • Respiratory distress syndrome and respiratory failure specificity
  • Meconium aspiration syndrome
  • Septic shock specificity
  • Necrotizing enterocolitis staging
  • Linking maternal conditions
  • Congenital/acquired conditions
  • Other severity drivers (e.g. acute kidney injury, fluid and electrolyte, apnea)

Even if the audits don’t turn up exactly what you thought they would, you will likely discover opportunities for documentation improvement through an ongoing audit process.

Editor’s note: This question was answered by members of the ACDIS Leadership Council. For more information about the Council, please contact Linnea Archibald (larchibald@acdis.org).