Communicate link between quality of physician documentation, quality of care

Healthcare reimbursement is increasingly moving from a quantity-based system to a quality-based one. A quick glance at the 2015 IPPS proposed rule and its quality focus proves the point.

 

Physician documentation drives those quality measures. If the physician fails to document a condition is present on admission, the condition may end up being coded as a hospital-acquired condition (HAC). That could negatively impact hospital quality scores and reimbursement.

 

The quality of care provided at a facility reflects the quality of the documentation and coding, says James Fee, MD, CCS, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, associate director of Huff DRG Review Services in Eads, Tennessee.

 

One problem, however, is that physicians were never taught how to communicate with coders. They are taught in medical school and residency that the purpose of the medical record is to communicate with their colleagues, Fee says. "That explains why the volume overload, pulmonary edema, the nondescript terms are written there, because a clinician will look at that and say, the patient has heart failure."

 

Physicians also don't know that their documentation is used as the basis for clinical grades and performance measures, Fee says. "Physicians don't understand what happens after the patient leaves the hospital." The physician's documentation is the data he or she can control.

 

Physicians being graded without knowing how to study for the test, Fee says. Give physicians tools, such as tip sheets and EHR prompts, to help them.

 

But without the documentation, coders can't tell the story of the patient and give the physician credit for what he or she did, Fee adds.

 

Physicians also don't always understand the importance of documentation for core measures. All of the core measure ratios are defined by the severity of risk the patient brings to the table, Fee says. That's the story the documentation should be telling, but physicians don't know that.

 

Clinicians and coders often speak different languages. Physicians talk to other providers in clinical terms, not diagnostic terms, Fee says.

 

Consider a patient who comes in with altered mental status with sepsis. "The physician knows that there is brain dysfunction because when you treat the underlying condition, the mental status gets better," Fee says. "Is it documented as encephalopathy? No. So you're not capturing the level of specificity needed and complexity treated."

 

While coders often understand what the physician means with the clinical terms, they can't code the clinical condition without the diagnosis being documented in the medical record. If the physician documents altered mental status, coders would report ICD-9-CM code 780.97.

 

However, if the physician documents septic encephalopathy, coders would report 348.31 (metabolic encephalopathy), which is an MCC. In fact, most of the encephalopathy codes under 348.3x (encephalopathy, not elsewhere classified) are MCCs, but altered mental status is not.

 

An experienced coder might say, the physician is treating this pneumonia with this antibiotic, so he or she knows the general clinical picture and what disease the patient has. He or she just can't code it.

However, that clinical knowledge can help coders craft efficient queries to get the documentation they need. In the pneumonia case, the coder might draft a query like this: 

 

Patient A, who has had a recent admission, resides in a nursing home with underlying COPD, chronic kidney disease and is being treated with X antibiotic. Can you indicate a more specific pneumonia that is being treated?

a. Gram negative pneumonia other than H. influenza

b. Atypical pneumonia

c. Streptococcal pneumonia

d. Other

e. Cannot provide further information

 

The coder is laying out the clinical indicators the physician has already documented (pneumonia, risk factors, and antibiotic). Now, he or she wants the physician to connect the dots for the specific type of pneumonia.

 

A query is not a fishing expedition, Fee says. "You're laying out the clinical indicators to give it back to the physician to say, we know what you're treating. Just say more specifically what you are treating."

The question in the query should use the information in the medical record. The answers should be supported by information in the record.

 

Queries are a key education and communication tool, Fee says. Physicians can see what information the coder is trying to get. Physicians, like almost everyone else, learn through repetition. If they are continually queried for the same information, they will eventually start to document it.

 

In addition, queries provide a way for coders and CDI specialists to show physicians which conditions will benefit from additional specificity.

 

The risk though is that physicians will document a condition even when the patient doesn't have it just to avoid a query.

 

Another problem is that as physicians move further away from their training and into the clinical practice, clinical terms don't always mean the same thing. One example is cor pulmonale.

 

Cor pulmonale is structural and functional changes of the right ventricle due to pulmonary hypertension. A patient can have cor pulmonale without congestive heart failure, just like a patient can have hypertensive heart disease without congestive heart failure. Physicians use that term in a clinical association that is not what it is the strictest diagnostic terminology, Fee says.

 

"Physicians equate cor pulmonale with acute right heart failure, which is technically not what it is," Fee says.

 

The best way to build physician engagement and buy-in is through peer-to-peer communication, Fee says. Then it becomes more of a discussion-- "What do you mean when you document cor pulmonale?" instead of "You're not documenting the patient's condition correctly."

 

Having a physician advisor can certainly help the process, Fee says. The physician advisor can talk on a peer-to-peer level with the physician and also help the coders and CDI specialists with clinical education.

Physician advisors perform a wide range of duties including:

 The physician advisor needs to be a respected peer with leadership qualities and with up-to-date, evidence-based clinical knowledge, Fee says.

 

ICD-10-CM will not eliminate problem areas for documentation, Fee says. If a condition is a documentation problem area in ICD-9-CM, it will likely continue to be a problem in ICD-10-CM.

 

ICD-10-CM requires more specificity than ICD-9-CM for many diagnoses, so queries will likely increase. Coders and CDI specialists can query for numerous things in ICD-10-CM, but they should focus only on the information that will impact payment, performance reporting, or profiling first.

 

Before sending a query, coders should look to make sure the information isn't somewhere else in the medical record. For example, a physician documents a left arm fracture. Instead of querying the physician for more detailed information--type of fracture, displaced or non-displaced, open or closed, exact location--coders should check for a radiology report.

 

If the radiologist documented a torus fracture of the upper end of the right radius, coders can use that information to assign the correct ICD-9-CM or ICD-10-CM code, says Kristi Stanton, RHIT, CCS, CPC, CIRCC, AHIMA-approved ICD-10-CM/PCS trainer and AHIMA ICD-10 ambassador. Stanton is a senior consultant with the Haugen Group in Denver.

 

The AHA's Coding Clinic for ICD-10-CM/PCS addressed this in the First Quarter 2013 issue. As long as the physician documents that the patient has a fracture, coders can pull details such as laterality and specific parts of the bone from the radiologist's report, Stanton says. Coders can do the same thing in ICD-9-CM.

 

ICD-10-PCS will present some significant problems that could result in queries, Fee says. Each ICD-10-PCS code must have seven characters and each character represents a specific piece of information. Coders need each piece of information in order to build the correct ICD-10-PCS code.

However, physicians currently don't report body parts and devices in a way that can be linked to ICD-10 PCS, Fee says. Start now to train physicians to document that missing information.

 

"Look at your top procedures and educate the physicians about what they need to know and document," Fee says. Make the education concrete and concise. If they are already documenting an element, don't spend time discussing it. Mention it, tell them they are already documenting it, and move on.

 

Spinal surgeries could be particularly problematic, because the devices in ICD-10-PCS don't match up with the physician definitions of devices, Fee says.

 

Some queries will actually go away in ICD-10, Fee says. Coders will no longer need to query for excisional debridement. The root operation in ICD-10-PCS will be excision. In addition, coders won't need to query for benign or malignant hypertension. ICD-10-CM includes only one code for hypertension-I10.

 

Physicians are focused on caring for their patients, Fee says. So documentation improvement or ICD-10 education needs to be as concrete and relevant as possible.

 

"You want to make it as specific to the individual or practice as possible," Fee says. Look at the provider's charts and customize the message based on what that particular provider does not document well enough. Tell the physician what he or she needs to focus on based on his or her records. That will help make the change seem more doable as well as more relevant.

 

Education should also be ongoing. Queries are the best way to provide ongoing education. Also consider newsletters and short departmental presentations.

 

Don't be afraid to play on physicians' competitive instincts, says Jane Bonewell, RHIT, senior consultant with the Haugen Group. Provide some peer- specific comparisons at a department meeting. Rank physicians anonymously.

 

For example, with physician A, the coders can code 100% of the records to the highest level of specificity. For physician B, coders can code 80% of the records. For physician C, it's 35% of the records.

Physicians will start to wonder who physician A, B, and C are, Bonewell says. "That peer-to-peer communication is where you get better physician buy-in than from a coder, HIM person, or CDI person educating them."