By Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS
Clinical specificity in medical record documentation is necessary to ensure accurate ICD-9 CM coding. It also ensures compliance with Medicare and other third-party payer guidelines and policies, including the ICD-9-CM Official Guidelines for Coding and Reporting.
Numerous studies have unequivocally demonstrated that the quality of clinical documentation directly correlates with the quality of reported care as well as patient outcomes. Effective and accurate quality of care reporting is essential to a hospital’s financial health, particularly in light of the transition value-based reimbursement.
Quality clinical documentation ensures communication among medical personnel and is vitally important to the assessment, planning, implementation, continuity, and evaluation of quality medical care. It also ensures reasonable and accurate reimbursement under the prospective MS-DRG payment system.
Clinical documentation improvement (CDI) programs have become the mainstay of a hospital’s strategies to successfully meet the financial challenges of decreasing reimbursement from third-party payers.
Clinical specificity generally translates to higher-severity diagnoses that, in turn, equate to higher reimbursement under the MS-DRG reimbursement system. CDI programs typically focus on the following:
- Acute or acute-on-chronic congestive heart failure (CHF) vs. CHF unspecified
- Sepsis vs. urinary tract infection
- Acute respiratory failure with chronic obstructive pulmonary disease (COPD) exacerbation vs. COPD with hypoxemia
However, establishing a CDI program doesn’t guarantee compliant documentation and/or coding. Queries that focus on obtaining ‘buzz’ words that add reimbursement but don’t add anything to clinical care overlook these two important factors that relate to overall revenue integrity:
- Clinical context
- Quality of clinical documentation
Both of these factors are essential for decreasing the financial risks associated with Recovery Auditor, Medicare carrier, Fiscal Intermediary, and Medicare Administrative Contractor (MAC) post-payment and pre-payment reviews and recoupments.
As stated in the most recent Recovery Audit Program Final Scope of Work, Recovery Auditors are required to employ registered nurses and clinicians who must review medical records for medical necessity and clinical validation.
The Scope of Work goes on to discuss clinical validation as involvinga clinical review ofthe case to determine whether the patient truly possesses the conditions that were documented in the medical record. Clinical validation is performed by a clinician (RN, clinical medical director, or therapist) and is beyond the scope of DRG (coding) validation and the skills of a certified coder.
According to the Guidelines for Achieving a Compliant Query Practice, published by AHIMA, compliant queries are those that include clinical elements and abnormal diagnostic work-up findings.
However, physician responses to these queries can—and often do—fail to accurately, adequately, and effectively capture clinical judgment, clinical analysis, and medical decision-making.
Diagnostic conclusion statements previously carried sufficient weight for coders to confidently assign an ICD-9-CM diagnosis code that would withstand the test of time in the event of an outside review. However, these statements are insufficient as a matter of clinical documentation integrity when they don’t incorporate a clinical context for understanding.
The clinical context of the documentation plays an integral role in establishing medical necessity for the hospital admission as well as the patient’s continued stay.
Insufficient documentation is a primary driver of medical necessity denials. Such documentation includes:
- Inadequate initial history and physical (H&P)
- Inadequate history of present illness (HPI)
Cloned medical record documentation
- Lack of consistency in clinical documentation throughout the record
- Omission of all relevant diagnoses including the queried diagnoses in the discharge summary
- Basic lack of clarity in terms of patient severity
How often does a CDI specialist or coder see documentation in an H&P such as ‘patient is now currently pain free,’ or ‘patient is alert and oriented x 3 in no acute distress,’ or ‘No new complaints, doing better, appears comfortable, no further chest pain’?
Cloned documentation is very problematic in most institutions and is a major factor in contributing to clinical medical necessity denials. According to Palmetto GBA, a MAC, the term ‘cloning’ refers to documentation that is worded exactly like those in previous entries. This may also be referred to as ‘cut and paste documentation’ or ‘documentation carried forward.’
Cloned documentation may be handwritten, but it generally occurs when using a preprinted template or an electronic health record (EHR). Although using templates in the her is acceptable, multiple patients are unlikely to have the exact same problem and symptoms and require the exact same treatment for every encounter.
Cloned documentation doesn’t meet medical necessity requirements for coverage of services. This type of documentation will surely lead to denials of services due to lack of medical necessity.
Strive for superior documentation
The following case study represents best practice for appropriate and proper documentation in support of the clinical context and medical necessity for admission.
Chief complaint: Chest pain, headache, cough, and fever unabating
HPI: The patient is a 35-year-old female who initially came to the ED two days prior with complaints of a severe, bothersome, ongoing cough for one week, productive of thick yellow sputum. She has also had a fever for three days as well as worsening shortness of breath present mainly on exertion. She also had chest pain in the substernal area that has been continuous and worsening for the past four days, but increased with coughing. She has had headaches for approximately three days and primarily when coughing. She has had decreased p.o. intake for two days. In the ED, she was given IV Rocpehin x 1 and sent home with a prescription for Biaxin™. The patient stated that she did fill the prescription but that she was taking Motrin® and Tylenol® for the pain. She stated that neither medication helped her and that her temperature went up to 103°. Thus, she came back to the ED. In the ED, a chest x-ray was repeated today. The x-ray continues to show left lower lobe infiltrate that worsens with increased haziness and more of a white out picture. Her white count was 15,000 with 12 bands, 18 neutrophils. As a result, it was determined that the patient had failed outpatient treatment and required inpatient hospital admission.
Impression and plan: Pneumonia with sepsis. The patient is being admitted because she meets the severe sepsis criteria with temperature of 103°, tachycardia with heart rate of 140, infection of pneumonia, and white blood cell count 15,000 and neutrophils 18. She has also failed reasonable outpatient management. She is being placed on IV Rocpehin and IV Zithromax®. Blood cultures have been sent. She will get Duoneb® and be placed on pneumonia protocol.
Taking a synergistic approach
Clearly, the clinical documentation in the above case study accurately and effectively captures the patient’s true severity of illness and the physician’s clinical judgment, thought processes, and clinical rationale for admission.
In its FY 2014 IPPS final rule, CMS states that there will be a presumed inpatient status when a patient remains hospitalized for two midnights. Effectiveness of clinical documentation in support of the physician’s decision to admit as an inpatient assumes even more importance in light of this change.
Auditors will be looking for a clear outline of the physician’s clinical rationalization and reasonable expectation of a hospital stay that spans two midnights. Diagnostic conclusion statements will no longer sufficiently capture the clinical context and medical necessity for inpatient admission.
The most effective approach to CDI involves synergy between coders and CDI specialists. The query process can—and must—expand beyond the traditional realms to incorporate clinical context and medical necessity. This will take a collaborative approach involving the CDI and the coding staff.
CDI specialists are on the front line, and they have the opportunity to reach out to physicians and provide one-on-one education about:
- Perils of the EHR
- Cutting and pasting documentation,
- Need for succinct documentation of the HPI
- Need for progress notes that provide an accurate account of a patient’s progress while he or she is hospitalized
Coders review the record at its completion, essentially acting as an outside reviewer.
Quality documentation is an essential part of the revenue cycle process. When considering the quality of your documentation, ask yourself the following question: What purpose do CDI specialists and coders serve if the hospital fails to be reimbursed for the excellent clinical care provided? Your answer will be the impetus to expand the thrust and focus of CDI.
Editor’s note: Krauss is senior manager with Accretive Health in Chicago. Reach him at gkrauss@accretivehealth.com.