by Trey La Charité, MD
My parents always warned to take anything a salesperson says with a grain of salt. Over the years, my experiences proved that advice wise. I never expected, however, to apply that same wisdom within the field of medicine. Naively, I assumed there was no room for misinformation when dealing with patients’ lives.
I have found, however, that a healthy skepticism needs to be applied within the realm of clinical documentation integrity. In fact, I am thinking of hanging “caveat emptor,” which is Latin for “buyer beware,” over my desk!
Unfortunately, today, new procedures, devices, and medications are rarely introduced to the medical community by a healthcare clinician. Instead, a salesperson touts the “next best thing” to our medical and administrative colleagues. A successful salesperson must first educate the buyer about his or her product and then entice the purchaser to complete the transaction.
To be clear, I am not questioning the integrity of the people who work in the sales field. However, all prospective buyers need to remember one simple fact: salespeople are paid to tell a carefully crafted version of the truth, and all companies put forth the version that paints their product in the best light.
This manipulation of data is inherent in the sales process, regardless of the product. To illustrate my theory, I offer an anecdote from within my facility.
New procedure
Recently, my hospital began offering a new elective procedure that involves the placement of a very expensive corrective device. While our administration clearly understood that we would probably lose money offering this procedure, they felt that it was necessary to offer this service for our patient population and to maintain our local market competitiveness.
During the implementation process, the device manufacturer sent a "revenue cycle representative” to ensure that we maximized the available financial returns from performing this procedure. During the representative’s presentation, the statement was made that our facility would earn an average of X dollars per procedure. This revenue estimation assumed that we would always be submitting the highest possible corresponding MS-DRG due to all of the “obvious” MCCs that would be present because this procedure is only performed on very sick patients.
This version of the truth later had to be dispelled. While my facility could receive X dollars every time we submitted the highest possible corresponding MS-DRG, this procedure fell into a traditional, three-tiered MS-DRG, meaning the available options were:
- MS-DRG without a CC or MCC
- MS-DRG with a CC
- MS-DRG with an MCC
Therefore, the real issue was how many times we would actually submit the highest possible MS-DRG (the one with the MCC) when we performed this procedure.
The first thing to realize is that this is an elective procedure we were discussing. Therefore, before a healthcare provider performs any elective procedure, they always ensure the patient is as stable as possible before proceeding to the operating room. In other words, our providers do not perform elective procedures on patients with acute respiratory failure, acute systolic heart failure, severe malnutrition, or any form of shock.
Therefore, proceduralists generally don’t do elective things on patients who have MCCs, which would make it highly unlikely for our facility to ever submit the highest possible MS-DRG for this procedure. Obviously, this salesperson did not understand the most basic elements of medical practice, coding, or the MS-DRG system and, as a result, spread misinformation—even if, at best, it was inadvertent.
Additional diagnoses
Another example associated with this same elective procedure again emphasizes the need for caution and skepticism by clinical documentation improvement (CDI) professionals. Our coders discovered a pre-printed form supplied by the device manufacturer designed as a documentation improvement aid. The form presented an extensive list of possible secondary diagnoses that might be commonly associated with the patient population undergoing this procedure—with boxes to check next to each one.
While we applaud methods that attempt to improve documentation for our providers, this form had some significant problems. First, every individual diagnosis listed on the sheet was either a CC or an MCC. Second, each individual diagnosis was clearly marked as being either a CC or an MCC. And last, all of the diagnoses that were CCs were grouped together and then sequenced before all of the diagnoses that were MCCs. The problems with this “documentation improvement” form were clearly extensive and troubling.
Remember that for any additional diagnoses to be coded, they must be clinically present and fulfill one of the five recognized criteria to be considered a valid secondary diagnosis. However, there is a significant compliance risk if a provider is misled to document diseases that are not present or had no bearing on the case. Additionally, indicating the financial ramifications of documenting specific additional diagnoses is highly frowned-upon by CMS and the Office of Inspector General (OIG). Finally, when a provider possesses a pre-printed packet of forms, the risk of just randomly checking a few extra boxes to give the impression that he or she satisfied a perceived documentation requirement is great. My hospital ultimately viewed this form as a significant risk factor for regulatory discipline and forbid its use.
Computer-assisted coding
A final example of the buyer beware principal within the realm of CDI is exercising caution with computer-assisted coding (CAC). Given the eventual arrival of ICD-10-CM/PCS and all of the concerns around productivity decreases associated with its implementation, CAC has been put forth by many as the ultimate solution.
A quick search of the Internet will generate a lengthy list of highly-touted CAC benefits including improved coding accuracy, improved coder productivity, improved consistency, improved compliance, increased revenues, decreased coding costs, and a smooth transition to ICD-10.
However, while CAC may provide many of these benefits, it simply cannot eliminate all of the projected productivity decreases associated with ICD-10. Therefore, your coding departments and CDI programs should plan accordingly.
An additional risk of CAC is the potential for generating inaccurate coding. A computer algorithm simply cannot replace clinical experience and intuition. As an example, consider a patient’s chest x-ray which has been officially read by the radiologist as an “infiltrate consistent with atelectasis vs. pneumonia.” In this example, the patient’s treating physician doesn’t believe that infiltrate represents pneumonia and does not start any antibiotics. A CAC program, however, might still suggest a query to the CDI specialist or provider asking for the diagnosis of pneumonia based solely on the program’s detection of the word pneumonia in the chest x-ray report.
If the CDI specialist or provider doesn’t take the time to validate the suggested query in the context of the complete medical record, a potential up-coding error may occur. Alternatively, providers may routinely click the yes or no buttons of various screen alerts simply to move through their electronic medical record as fast as possible due to the phenomenon of alert fatigue.
I already suffer from this problem as I regularly use Computerized Provider Order Entry (CPOE) when taking care of patients. During the initial implementation of CPOE at my facility, our providers were inundated with a large volume of pharmacy-related alerts. As this problem took several months to correct, many of our providers clearly developed alert fatigue, resulting in repeated, reflex-driven “no” clicks without ever fully reading the alerts. This behavior, therefore, has the potential to down-code medical records if the providers always click no to every electronic CDI query presented simply so they can make a quicker transition to the next patient.
CDI specialists need to closely scrutinize the promises put forth by hospital product vendors. Blind belief in the proclaimed benefits of any new product may lead to disappointment and significant future liabilities. While I recognize and appreciate our vendors' efforts to improve the world in which we practice, they cannot make new products without first selling their current inventory. My suggestion is to conduct a critical and thorough review prior to purchase and implementation to eliminate unrealistic expectations.
Editor’s Note: Dr. La Charité serves as the physician advisor for UTMCK’s Clinical Documentation Integrity Program, Coding, and RAC response. A hospitalist at the University of Tennessee Medical Center at Knoxville, he is board certified in internal medicine and a clinical assistant professor with the Department of Internal Medicine. His opinions do not reflect necessarily those of UTMCK. He is also a former advisory board member for the Association of Clinical Documentation Improvement Specialists (ACDIS). Contact him at Clachari@UTMCK.edu. This article originally appeared in the ACDIS CDI Journal.