CMs', coders' role in documenting POAs

CMs can identify where process breakdowns occur

Case managers should be involved in their hospitals' efforts to ensure compliance with the Centers for Medicare & Medicaid Services (CMS) regulations that require documentation of conditions that are present on admission and deny payment for certain conditions acquired during the hospital stay, experts say.

"Case managers are not ultimately and totally responsible for capturing and ensuring that conditions that might be present are documented in the medical record. But the role they play puts them in a position to identify incidences when it is not occurring, determine where the process barriers are, and where breakdowns occur," says Lorraine Larrance, BSN, MHSA, CPHQ, CCM, manager with Pershing, Yoakley & Associates.

CMS began requiring hospitals to document conditions that are present on admission in October 2007. Beginning with admission on or after Oct. 1, 2008, CMS will not pay for certain hospital-acquired conditions.

Assess at admission

When patients are admitted, the care team should assess whether they are at risk for a hospital-acquired condition, develop strategies to avoid it, and also document any conditions that are present, says Leslie Schultz, RN, NEA-BC, PhD, CPHQ, director, knowledge transfer for Premier Inc., an alliance of not-for-profit hospitals and health care systems in Charlotte, NC.

"Everyone — case managers, physicians, and other clinicians — needs to understand the importance of ensuring that the appropriate information is captured at the right time and right place so that the coders can document that the condition was present on admission," she says.

Case managers should make sure that there is a complete assessment of patients at the time of admission so the record accurately reflects what conditions they came in with as opposed to what developed during the course of the hospital stay, Schultz suggests.

Track diagnoses that are listed as "present on admission" and those that develop during the hospital stay and identify areas for quality improvement projects, she adds.

While assigning diagnoses codes and correlating "present on admission" indicators is the primary responsibility of the coding staff, case managers who are involved in clinical documentation improvement must make sure that all conditions that are present when the patient is admitted are included in the documentation, Larrance adds.

That will enable coders to identify the appropriate sequence of diagnoses as they review the charts and note which conditions were present on admission.

POA indicators

There are five "present-on-admission" indicators, one of which much be assigned to each inpatient diagnosis: Y for yes; N for no; U for "insufficient information in the record to determine if the condition was present" and W if it can't be determined clinically whether the condition was present at the time of admission.

It's the "U" indicator that is the most problematic, says Carol H. Eyer, RHIA, CHC, senior manager of clinical compliance with Pershing, Yoakley & Associates' Atlanta office.

"U is a bit of a nebulous area, indicative of either unclear or absent documentation. An assignment of a U is basically one step away from an assignment of an N indicator," she says.

As is the case with MS-DRG assignments, coders are not allowed to exercise discretion in assigning a condition as "present on admission" unless it is clearly documented in the medical record, Eyer points out.

"Coders are limited by industry standards and rules where it comes to making assumptions. We can look at the tests the physician ordered, the lab values, and other diagnostic results and intuitively know that the patient probably had this problem on admission but unless the physician documents the diagnosis, we can't assign the present on admission indicator," she says.

The clinical documentation should reflect conditions that may be suspected at the time of admission, Eyer points out.

"For instance, physicians may not be able to say unequivocally that a patient has a kidney infection but they can note the presence of bacteria and possible causes as well as documenting orders for diagnostic laboratory work that they expect to reveal that condition and prompt other clinical intervention," Eyer says.

If the physician writes that the patient has a "suspected" or "probable" diagnosis, the coders can use the documentation to assign the present on admission indicator, she adds.

Coding in the ED

The hospital emergency department offers some of the greatest opportunities for ensuring that the proper documentation is captured, Eyer says.

The emergency department physician may capture the details of a condition that is present or evolving at the time he or she is assessing the patient but the attending physician may not include this in his or her inpatient documentation in a way that the coders can capture the condition as being present on admission, she adds.

Make sure physicians understand the additional coding requirements, Larrance adds.

"Case managers who have a role in clinical documentation improvement efforts already have a process in place to work with the coding staff and providers. This is just one more method of querying the physician," she says.

For instance, if a case manager is reviewing the chart of a patient who comes in with a Foley catheter and notices that the urinalysis indicates white blood cells, he or she should look in the chart and see if "urinary tract infection" or "suspected urinary tract infection" is documented.

If not, the case manager should query the physician regarding the clinical finding, which would prompt the physician to ensure that clinical documentation is sufficient to support his clinical findings as well as to support the presence of the Foley catheter on admission.

"I don't see case managers as being totally responsible for capturing conditions that are present on admission, but as a member of the team who reviews the patient charts, they should work collaboratively with other disciplines to make sure the documentation is complete," Larrance says.

CMs in the ED

Since many hospitals admit the majority of their patients from the emergency department, the requirement to report "present on admission" data makes it even more important to have case managers in the emergency department, Larrance says.

"The value of case managers in the emergency department has been demonstrated for many different reasons, and this new layer of regulation criteria that can impact reimbursement reinforces that value," she says.

Querying docs important

Case managers who are assigned to the emergency department have an opportunity to query the emergency department physicians, nurse practitioners, or physician assistants who treat patients in the hospital to ensure that any condition that is present is documented, Larrance says.

"Ultimately, the medical staff are responsible for the clinical documentation but members of the interdisciplinary team can help by prompting physicians to learn new behavior," she says.

In addition to the emergency department care managers, admissions nurses also can be involved in the process and alert physicians if there is an indication that the patient may be coming in with an additional condition, Larrance adds.