ED case manager improves physician documentation

Efforts focused on staff, clerks as well

While few hospitals have yet extended their case management system into the emergency department, some have discovered the value of ED case managers in ensuring accurate documentation and coding. A good case in point is Saint Vincent’s Hospital and Medical Center in New York City. Susanne Greenblatt, RN, MA, the hospital’s ED case manager, and consulting editor for ED Documentation & Coding Update, says her focus varies from day to day and sometimes from hour to hour, depending upon what she thinks is most important. However, a primary focus is reimbursement.

Her other immediate concern is to screen ED admissions for appropriateness. That includes reviewing the initial admission diagnosis prepared by the physician. Greenblatt explains that double-checking the first diagnosis is key "because that is what gets faxed to the insurance company, and then they get into a certain mindset about the patient." And that mindset can have an impact on whether a claim ultimately is denied or reimbursed appropriately.

For example, it’s fairly typical for Greenblatt to come across a chart on which the admission diagnosis is listed as "pneumonia. I ask, Isn’t that the elderly person who is intubated and on a ventilator, on vasopressors, going to go to the medical intensive care unit?’ I then suggest pneumonia requiring mechanical ventilation adding clinical sepsis, or septic shock, depending on the patient’s blood pressure."

Such accuracy is important even at the very beginning, Greenblatt says. "Because if the insurance company gets something faxed that just says pneumonia,’ they’re going to ask why the person didn’t go home on oral antibiotics."

Some of it is knowing the semantics, she says. "Any time you use rule-out in a diagnosis, if that disease process is ruled out, it opens the door for the insurer to say, Oh, you were wrong. We’re not going to pay for the admission.’ Whereas if the doctor changes just one word and uses clinical’ — for instance, clinical sepsis’ — then even if the blood cultures are all negative, if they clinically thought the patient was septic, and they are treating the patient for that, the insurance company will pay."

Educating physicians about terminology

"So some of that is just learning the terminology that the insurers demand we use in order to be reimbursed for the admission. And doctors certainly aren’t educated about these kinds of things," she says. Greenblatt, however, is doing her part to help educate them, through one-on-one interaction as well as at the biweekly meetings of attending physicians. She notes that the physicians generally are receptive when she suggests that something be documented in a certain way.

These days, physicians often will come to her when they’re unsure how to document something. "They’ll think that the words that they would use might not be correct, and they’ll actually come and say, How do you want me to write this?’ That’s actually how they put it — how do I want them to write it."

In the Saint Vincent’s ED, on any given shift, there may be up to four attending physicians, four medical or surgical residents, and two interns. Maintaining proper documentation can be particularly challenging when the ED is especially busy. That’s when Greenblatt is most dependent on physicians taking the initiative to let her know when they’re admitting someone. "And they either tell me what diagnosis they’re going to use, or I ask them how they’re going to word it."

She notes that the clerks have been very helpful in this area. "When they see a chart that has abdominal pain’ as the admission diagnosis and somehow I didn’t hear about that patient because I’ve been busy doing something else, they’ll call me. Now, they actually think it’s funny: You’re going to love this,’ they say. Or they’ll actually tell the doctor, Susanne’s going to be talking to you about this; don’t you need to write more?’"

Physicians often don’t take credit for all that they do, particular at the beginning stages of a case, Greenblatt points out. For example, "if someone comes in respiratory arrest, there are many diagnoses that go with that — depending on the length and cause of the condition." If the physician effectively addresses those problems right away, "then they tend not to use them as diagnoses, because those problems have already been corrected."

Greenblatt stresses, not only to physicians but to staff as well, that proper documentation is important to the survival of the organization. "It benefits everybody to do this right from the beginning. I say to the doctors, You have to care about this because you have to have a hospital to practice in.’ And to the clerks, I want the hospital to get paid so you get paid.’ That makes it a little more personal," she adds.