A few words may affect case mix, reimbursement

Ensure documentation reflects patient's condition

When it comes to coding, a rose by any other name may mean that your hospital isn't getting the reimbursement it deserves.

In fact, a few words can make the difference in an accurate DRG assignment and have an impact on the reimbursement your hospital receives, the hospital case mix index, and ultimately how the hospital and the physician fare on public report cards.

If documentation isn't clear or specific enough, it can't be coded at the greatest accuracy. The hospital may receive less than the reimbursement deserved for resources expended on a patient's care because the assigned DRG does not represent the true severity of illness and the level of care, says Carol Eyer, RHIA, clinical compliance senior manager with Pershing Yoakley & Associates' Atlanta office.

"Seasoned coders often are able to look at the clinical indicators and recognize what the patient is treated for but they are not able to make leaps in clinical judgment as nonclinicians or make coding decisions when this is not clearly documented by the physician," Eyer says.

Coders are closely regulated from a compliance standpoint and must be cautious not to make clinical assumptions they are not qualified to make, she points out.

Better documentation allows the hospital to more closely reflect the resource consumption of the patient, which is essential since the current DRG system payment rates are based on resource consumption, Deborah Hale, CCS, president of Administrative Consultant Services LLC, a health care consulting firm based in Shawnee, OK.

For instance, if someone comes in with chest pain and the only documentation in the chart is "chest pain," the patient's diagnosis falls into a DRG with a low relative weight. But if the documentation is clearer, indicating angina in a patient with known coronary artery disease, it changes the relative weight and increases the geometric mean length of stay and reimbursement, Hale says.

Surgical patients often represent an opportunity for improved documentation and higher reimbursement by documenting comorbidities and complications, Eyer says.

However, surgeons typically focus on the condition that requires a procedure, rather than the other medical conditions that affect the patient's course of treatment, she says.

But if comorbid conditions or complications, such as congestive heart failure, diabetes, or urinary tract infection, are clearly documented in the chart, it may bump the patient into a higher-weighted DRG, she adds.

"When patients are moved into a higher DRG, the increase in relative weight for that case may be only incremental; but if you have 100 patients, an incremental bump in relative weight can significantly can change the case mix index and can result in more revenue," adds Doris Imperati, BSN, MHSA, CCM, managing consultant for Navigant Consulting, a consulting firm with headquarters in Chicago.

In order for coders to correctly assign a DRG to the patient's diagnosis, the clinical terms used by the physician to document the patient's condition must match the current coding definitions issued by CMS, Imperati adds.

For instance, physicians tend to use the term "urosepsis" when a patient has a urinary tract infection and the bacteria leaks into the general vascular circulation, causing septicemia or the lab and vital signs support the diagnosis of sepsis.

"Physicians all over the country call the scenario 'urosepsis' and when they do, the coders cannot represent the true clinical condition of the patient," Hale says.

For coders, "urosepsis" translates to a common urinary tract infection that would not warrant admission to the hospital.

The correct term would be septicemia or sepsis, secondary to a urinary tract infection, Hale says.

Documentation enhancement does not mean misrepresenting that patient's condition or the treatment provided; it clarifies what really happened. In this case, it means that a localized urinary tract infection has developed into a systemic infection, or a systemic inflammatory response to that infection, Hale says.

"In many cases, the documentation in the chart doesn't translate into the patient's severity of illness. The patient's condition seems obvious to the doctor from a clinical standpoint but it's not so obvious to the coder and it cannot be most accurately coded from the documentation provided," Eyer says.

For instance using the term "type 2 diabetes — poorly controlled" does not qualify for higher severity but "type 2 diabetes — uncontrolled" does, Hale says.

"Physicians learned a different lingo in medical school. Knowing how to document to accurately represent the patient's severity of illness is not education that most physicians get as part of their training," Hale adds.

Sometimes physician documentation actually reflects a better picture of the patient condition than the clinical term used to code the same condition, Imperati says.

For instance, if a patient has blood in the urine, the physician may write "cherry red urine" on the chart so other health care providers have a clear picture of the urine's color at that point in time. Unless the physician uses the word "hematuria" in the documentation, the true condition of the patient can't be coded, Imperati says.

"We work with the physicians and educate them on language that is codeable. In this case, we ask them to use the word 'hematuria' in addition to the description of the urine, which adds further clarification to the color or extent of the hematuria," Imperati says.

Another common coding problem is the documentation of "blood loss anemia," Imperati says.

"There are several different types of anemia but they are not all comorbidities that will bump up the diagnosis to a higher-weighted DRG. Blood loss is a common cause for anemia, but it is often documented only as 'anemia,'" she says.

To be coded as a comorbidity, the anemia must be linked to blood loss using documentation such as "anemia due to blood loss," "anemia due to GI bleeding," or "acute blood loss anemia," Imperati adds.

Physicians often think that the slash mark (i.e., GI bleed/anemia) infers that the conditions are linked. In reality, the conditions can exist independent of each other, which is why documentation has to reflect that the anemia is directly related to the blood loss, she adds.

"Anemia due to blood loss, acute or chronic, is an often-missed complication/comorbidity [CC] and in cases that do not have another CC, this can make a difference in the correct DRG assignment and reimbursement," Eyer says.

The lab values may reveal that the patient has decreased hemoglobin and hematocrit levels and the chart may reflect a transfusion of two units of blood but the physician does not document that the reason for the transfusion was anemia, she adds.

"Coding guidelines indicate that clinical assumptions may not be made on behalf of the physician and this includes interpreting diagnostic test results. The physician would need to document that condition being treated, such as suspected blood loss anemia, before this documentation could be coded as CC," Eyer says.

(Editor's note: Check out the May issue of Hospital Case Management for a case study of a documentation improvement project.)