Critical Path Network

CMs partner with coders for appropriate documentation

A documentation enhancement project that pairs case managers and coders increased the Medicare case-mix index at North Mississippi Medical Center from 1.48 to 1.92 in six years for the Tupelo, MS, hospital.

The hospital's case managers take the lead in the documentation enhancement efforts.

Case managers are unit-based and typically coordinate the care of specific populations on that unit. This gives them an opportunity to develop a close working relationship with the physicians and to become specialists on coding for the diagnoses that most frequently occur among the population on their units.

"The case managers are in the charts every day, reviewing patient care, severity of illness, and intensity of service. It makes sense to teach them the coding language so they can teach the physicians in small increments," says Jan Englert, RN, director of outcomes management.

The documentation enhancement project has been an evolving process, says Joellen Murphree, RN, CPHQ, CCM, director of clinical quality and patient safety.

"Our goal is to produce documentation that gives a true picture of the patient in the coding language that will result in appropriate reimbursement for the care we provide. We are very conservative in our approach to the coding rules to avoid even the appearance of a violation," Murphree says.

The hospital began the documentation and coding enhancement initiative in 1998 by hiring a consultant, who conducted an extensive educational program on documenting and coding for the hospital's coders, case managers, and physicians.

The consultant presented an overview class once a week for four weeks for the case managers and coders and returned at intervals over a two-year period to work with the staff. The case managers and coders assigned to specific units reviewed charts with the consultant to become familiar with the nuances of coding.

"The goal was to enable the case managers to do concurrent coding on the nursing unit so the coder can just verify and add from the discharge summary," Murphree says.

After the initial educational sessions, the case managers began to code the diagnosis for Medicare patients in the charts on the nursing units.

Physician advisers

The coders would review the case managers' work and meet with all of the case managers once a month to discuss the cases in which they disagreed with the case managers' coding. When there were questions, they'd review the charts with the consultant.

"The coders began to trust the case managers, and, rather than redoing their work, they could validate it," Murphree says.

In the beginning, the case managers and the coders kept tally sheets listing problems they found in documentation. They gave them to the consultant, who based educational sessions with the physicians on where improvements were needed.

The hospital contracted with a retired medical doctor and a retired surgeon to be physician advisors for documentation. The physicians went through extensive training with the consultant and conduct retrospective chart review. They meet periodically with the physician sections to talk about areas for improvement.

When case managers have questions for physicians about documentation or discharge planning, they write it on a lavender (the case management color) communication sheet and place it in the front of the chart. There is a space for the case manager to write a request for details, a space for physician comments, a notation of the current and expected length of stay for that DRG, and a section for discharge planning.

The physician advisors write a monthly documentation and coding newsletter in which they review the documentation required for a particular diagnosis or new requirements for documentation. For instance, one newsletter explains the difference in bacteremia, septicemia, systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock and discusses what documentation is required for each.

Assuring correct documentation

When new physicians join the staff, they spend time with the physician advisors learning the correct method of documentation.

When the case managers began to take on the additional responsibilities of concurrent coding, the team drew up a list of responsibilities that would help them set priorities for their day.

"A case manager's first priority is not to be a concurrent coder," Murphree says.

Reviewing discharges scheduled for the day has the highest priority on the list, followed by beginning the process of finding nursing home, subacute, and swing bed placements; reviewing charts; determining needs for home health, DME, and outpatient services; discharge planning discussions with physicians and staff; reviewing patients readmitted within 30 days and denial appeals; then concurrent coding.

Assuring correct documentation is complicated by the fact that not every patient fits neatly into a category for a DRG, Englert says.

For instance, a patient may come into the emergency department and have an original diagnosis of pneumonia but upon further study, the physician may determine that the patient's symptoms actually are caused by an exacerbation of congestive heart failure.

These are two very different DRGs, she adds.

"We have to establish the principal diagnosis early on so we can document it correctly from the beginning. We must look at what is going on with the patient and document what we do appropriately so we get credit for what we have done for the patient," Englert says.

Physicians find documenting for Medicare patients frustrating because the clinical language they use and the coding language often are very different, Englert points out.

"Clinical language used by physicians and the coding language are hardly ever the same thing," she says.

For instance, the physician may write on the chart that the patient's hematocrit has dropped and order a transfusion, then document that the hematocrit came up. Unless he or she uses the words "blood loss anemia," the coder can't code the DRG or complication.

"Coders are not clinicians, and they can't make any clinical judgment. They can only put down what a doctor writes, even though it may be obvious that the patient has blood loss anemia. They can't surmise what the physician really meant even though the record suggests it," she says.

Physicians often document what the patient needs clinically, but their documentation may not reflect what CMS requires for reimbursement, Englert says.

"There is a huge frustration among physicians because they are doing a good job at clinical documentation but what they document isn't what we need to place the patients in an appropriate DRG and be reimbursed appropriately for the care given," she says.

The way physicians document to bill for their services is different from what CMS requires in the way of documentation for the hospital to be reimbursed for its services, Englert points out.

"The language physicians are required to use for their own billing is more clinically oriented. The hospital side of Medicare requires a totally different type of language. The doctors may have done a great job of documenting the patient's clinical condition but through these efforts have learned a different skill set: the language of DRG coding," she says.

"Appropriate documentation ensures the correct reimbursement for the care given. Just as importantly, it improves the physicians' outcomes in risk-adjusted measures such as mortality, morbidity, and complications and prepares them to be successful under pay-for-performance reimbursement," Murphree says.

(For more information, contact: