Documentation goes beyond correct MS-DRG

RNs also focus on severity of illness, other issues

At DCH Health System in Tuscaloosa, AL, clinical documentation improvement efforts go far beyond just making sure the documentation supports the most appropriate MS-DRG for the purpose of Medicare reimbursement.

The 8.8 FTE clinical documentation specialists dedicated to the program review the charts of all patients, not just those covered by Medicare; focus on making sure that all conditions that could affect severity of illness and risk of mortality are documented; and review for concurrent interventions for core measures.

"It's important that the documentation accurately reflects the services the patient received for reimbursement purposes. However, if we ignore severity of illness or risk of mortality, it will adversely affect our benchmarks and how the hospital appears in publicly reported data," says Robin Holmes, RN, MSN, manager of clinical documentation improvement at DCH Regional Medical Center, a 580-bed regional facility, and DCH North-port Medical Center, a 204-bed acute care hospital with both inpatient rehabilitation and psychiatric specialty units.

If a patient comes in with multiple comorbidities, documenting only one can sometimes place the patient in the highest-paying MS-DRG, she points out.

"Once you get that one MCC [major complication/comorbidity], you're at the highest-level MS-DRG possible. If you have six MCCs, the payment is the same but the data may not accurately reflect severity of illness and risk of mortality," Holmes says.

It is critical to document the other complications and comorbidities. Complete documentation will reflect a true picture of the hospital stay, and it affects the hospital's benchmark data and publicly reported data, she adds.

"At one time, the dollars we could generate by improved documentation was our biggest focus. We have moved away from that to include the quality piece in our documentation efforts. We used to concentrate only on the cases where reimbursement was based on the DRGs. Now we're looking at everybody," says Brian Pisarsky, RN, BS, ACM, CPUR, director of case management services at DCH Regional Medical Center and DCH Northport Medical Center.

Some commercial insurers and Medicare Advantage plans are beginning to base copays on each hospital's quality of care as shown by publicly reported data, he points out.

"The quality data are important already, but they will be more important in the future. That's why it's important to focus on severity of illness and risk of mortality as well as reimbursement in any clinical documentation program," he adds.

For instance, insurance companies may steer their members to other facilities if a hospital's quality data show longer lengths of stay or a higher mortality rate for certain diagnoses than data from similar facilities, he says.

Hospital documentation must reflect every complication and comorbidity in order to present an accurate view of the patient's condition, Holmes says.

For instance, if a patient with coronary artery disease has open heart surgery and develops acute respiratory failure, those diagnoses alone will generate the maximum payment for the hospital because of the MS-DRG assignment.

However, if the patient also has an exacerbation of congestive heart failure and renal failure, and the physician documents "congestive heart failure" and "elevated BUN/creatinine dialysis orders" instead of "acute systolic congestive heart failure" and "acute renal failure," the hospital will still get the same payment but the coded chart will not reflect the actual severity of illness and/or risk of mortality.

"If the documentation shows the patient has a severity of illness and/or risk of mortality of Level 2 or 3 and he really met criteria for Level 4, the services the hospital provided are not accurately reflected in the publicly reported data," she says.

It's not uncommon for surgeons to focus on their specialties and not document other comorbidities the patient may have, Holmes says.

But under current coding guidelines, this documentation practice isn't good enough. The surgeon should document precisely, such as specifying "diastolic heart failure.

"This can be challenging because often the surgeon will acknowledge the congestive heart failure but cannot offer further specificity as to the type," she adds.

Since physicians are so focused on taking care of their patient, it's unrealistic to expect them to know all the language the government requires for accurate documentation, Holmes says.

"We are always working to build up a relationship with our physicians so if they have a question about documentation, they'll ask the clinical documentation specialists for help," she says.

At DCH Health System, the clinical documentation specialists are all RNs. They don't query physicians unless at least two clinical indicators are present to support a query.

"Documentation should always be about clarification and never about leading," she says.

In most cases, the clinical documentation specialists start out with written queries for the physicians. In some cases, they may make a verbal query when the physician is on the unit.

"Our staff practice under the guideline that we will never generate a query before a physician has the opportunity to document the diagnosis and/ or clarification. If we look at the chart before the progress note is done, we wait to make a query," she adds.

The team tracks trends, such as how many times they had to query a particular physician. If physicians are slow to respond, the physician advisor educates them about the impact poor documentation can have on their profile.

(For more information, contact Robin Holmes, manager of clinical documentation improvement at DCH Regional Medical Center, e-mail: