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While often perceived as the purview of physicians and coders, the complete and accurate documentation of medical records is an essential element of the performance improvement process, and it’s not all about numbers. After all, an inaccurate or nonspecific diagnosis can negatively impact treatment and outcome. Erroneous severity data can significantly affect benchmarking studies. And of course, inaccurate coding can result in a lower reimbursement than the amount to which you are entitled.
"Complete and accurate documentation for billing purposes has been the focus over the last few years," asserts Patrice L. Spath of Brown Spath Associates in Forest Grove, OR. "Because the information that goes into the clinical/financial database has so much impact on what we are paid, we tend to forget the original intent: to measure and monitor our performance."
From a financial standpoint, she notes, if a physician documents that a patient came in with chest pain but doesn’t indicate what might have caused the pain, then the resulting reimbursement may be lower than if the diagnosis had been better defined. "If it’s esophageal reflux, for example, the reimbursement will be greater than what it might be just for chest pain," she explains.
"As a quality manager, I may be tempted to say that’s not my problem — that it’s up to the doc and the coder," Spath continues. "But when I get back my comparative data from benchmarking studies, if I’m involved in ORYX, where chest pain is used as a denominator and the record shows that more of our patients with chest pains stay longer than expected, then it is my problem. And I end up having to go back to each of those individual medical records and find out what additional things might have been going on with those patients to cause them to look like each other.
"This could have been avoided if the doctor had been more specific in his coding," she points out.
Deborah Hale, CCS, president of Administrative Consultant Service Inc. in Shawnee, OK, emphatically agrees. "Coding has a major impact on the performance improvement processes," she asserts. "Process improvement looks to improve the management of patients with a particular diagnosis, but if that diagnosis is not properly reported, you may be acting on bad data."
Part of the problem is simply the development of bad habits, Spath says. "Accurate coding used to be the crux of our data collection prior to DRGs, but with coding related so much to payment now, we have forgotten its importance to our databases," she claims. "Some of it is habit. Prior to 1980, we weren’t using the information in our databases to do a lot of performance management activity, and we weren’t conducting a lot of hospital-to-hospital comparisons. So since our databases were not getting used for anything significant, we were not as careful to be specific. Coders developed bad habits; they basically coded what was on the face sheet of the medical record. And for the doctors, it was a lot easier to write chest pain’ than something more specific."
Problems also arise because staff do not have the information or the results from the retests prior to the patient being discharged. "Let’s say a patient was admitted with a fever of unknown origin,’" Spath says. "If the patient is discharged with that diagnosis then, depending on the studies, it could be a week or two to get back the test results. In our rush to want to code these charts and submit the bill for payment, we may not want to wait those two weeks before sending in the bill." Finally, she says, many physicians don’t appreciate the ramifications of their documentation, and their impact on financial and database accuracy.
Clearly, physicians hold the key to improving the coding process. How can quality managers gain their support and cooperation? One way is through education, Spath suggests. "Help the physicians understand the ramifications of their actions," she advises. "Give them some examples. Tell them, If you put chest pain on the chart, we get $1,800; if you put angina, we get $2,100.’ Since this is now the way we get paid, it’s affecting them as well as the hospital."
You also should point out how coding can affect the way your hospital looks in comparative reports, she says. "Doctors may tend to say it’s the coders who aren’t doing things right, but when you go to the medical records, you might find it’s the doctor who didn’t document properly," Spath says. "You may have to do some studies to show it’s a failure to completely document. For example, with severity adjustment data, our patients could look like they aren’t as sick as they really are because of the failure to accurately document comorbidities," she adds.
"I think sometimes physicians don’t document accurately because we haven’t shown as an organization that we are totally serious with it," offers Vicki Searcy, who heads Searcy Resource Group, LLC, in Laguna Beach, CA. "People respond when you set rules and show you will follow through and not knuckle under because of other factors."
Sometimes that can require an extraordinary commitment, Searcy says. "For example, you may require certain documentation in the records before a patient can go to surgery. If an organization has the fortitude to do so, [it] can stop the procedure before it starts if [it has] to," she says. "This can cause mayhem in the OR, but my experience is that you just have to set the stage with a few instances, and then word gets around that you’re serious."
Searcy says that probably the most effective strategy she has employed with physicians was peer pressure. "What we used to do was fill out our delinquency or deficiency counts quite regularly, and they were posted in a place the docs often went, like the surgery lounge or the dictating area," she recalls. "The docs didn’t like other docs knowing they were on the list."
The bottom line, Searcy says, is that physicians are extremely busy, and they will respond to the point of greatest pressure. "The key is to set the standards of what is required and what will happen if it’s not there — and stick to it. Otherwise, the whole thing is a sham."
One process that has been implemented by a number of facilities in order to ensure more accurate records is concurrent coding. But the jury is still out on the process. "A lot of people are moving toward concurrent documentation improvement, with case managers or health information management professionals responsible for reviewing charts while the patient is still in the hospital," Spath observes.
"They encourage physicians, either verbally or through written notes, to document more specifically. Often doctors will say something like, Patient has renal insufficiency.’ That’s a relatively nonspecific comment. Ideally, they should document chronic renal failure if, in fact, the patient has it; it’s a codable diagnosis. Being more specific may impact the severity score of that patient as well as impacting payment," Spath explains.
The aforementioned health care professionals can pick up these kinds of opportunities, she says. "They may write, Doctor, what is causing these chest pains? If you know, please document.’ Docs are like you and I; once they write something, they don’t want to look at it again. Once the discharge summary is dictated, it is out of their brain, and they may react with hostility [when asked to revisit it]. That’s why some people have moved to more concurrent coding review," Spath notes.
"The organizations where they stay on top of this issue are those where they have people regularly reviewing the charts concurrently," Searcy adds. "They may be case managers or utilization review people." Concurrent review has significant import from a QI perspective, she adds. "If the information is not there on a concurrent basis, it doesn’t provide the information that other caregivers need to adequately take care of the patient. "Another factor is the impact on being able to appropriately code and bill for the patient. Finally, there is the issue of compliance," Searcy says.
Despite its obvious benefits, concurrent coding will not solve the problem by itself, Hale insists. "For concurrent coding to work, you need the philosophy of the institution to change," she says. "Without that change, concurrent coding is not effective." Philosophical change requires a goal adjustment, she explains. "Your overriding goal should not be having the chart coded at the time of discharge, but rather having the information necessary to code at the time of discharge.
"You do need a concurrent process," she says. "The reason concurrent coding hasn’t worked in the past is that the goal was to have the record coded at the time of discharge. You had to re-code so many times it was not time-efficient. We now approach the issue from this perspective: know what DRG we’re in and what we need in some key DRGs, and focus on documentation. You still have what you need at the end of the process, but you record everything one time, rather than multiple times." For this process to work, Hale explains, physicians have to understand why they need to participate. "Otherwise they just see it as an added aggravation."