Focus on improved documentation of physicians’ clinical thinking, not DRG “buzzwords”

CGI Federal, the RAC for Region B (Indiana, Michigan, Minnesota, Wisconsin, Ohio, Kentucky, Illinois), has found a soft target: Medicaid claims for 1-2 day stays. RACs are contracted with other third party payers such as Medicaid to data mine historical provider coding and billing patterns and recoup past payments. Many of these denials and financial recoupments are “self-inflicted” by hospitals, often because physicians aren’t documenting patients’ risk factors or other clinical concerns, only vague symptoms such as chest pain (i.e., “chest pain rule out MI, start MI protocol”).

Too many CDI programs are focused on case mix and DRGs instead of taking a collaborative approach with physicians to improve documentation throughout the record. With nationwide RAC rollout upon us and complex record reviews slated to begin early next year, CDI specialists should work with physicians to help stave off this threat. One area in which CDI specialists can help is encouraging physicians to document their clinical thought processes, judgment, and medical decision making to complement and support diagnostic documentation.

We can’t make up what the doctor is thinking. We need to take documentation improvement to the next level, which is promoting and stressing to the physicians the importance of their patient clinical assessment—i.e., diagnoses, supported by a short discussion of additional clinical concerns and rationales that paves the way for the chosen plan of care.

Encouraging physicians to improve documentation of their thought processes is easier said than done, but an effective tactic is engaging physicians in a discussion on the interrelationship between E/M level assignment, clinical documentation (both in the office and in the hospital), and medical necessity.

While you can’t instruct physicians on what E/M level to select for his or her services—an inducement violation under Stark Law—you can help physicians understand the importance of complete and accurate clinical documentation in establishing medical necessity, the backbone of all E/M assignments.

For more information on education physicians on the concept of medical necessity as it relates to their E/M billing, refer to the following Job Aid on Trailblazer’s Web site. Some of the guidance Trailblazer provides includes the following:

Information used by Medicare is contained within the medical record documentation of history, examination and medical decision-making. Medical necessity of E/M services is based on the following attributes of the service that affected the physician’s documented work:

• Number, acuity and severity/duration of problems addressed through history, physical and medical decision-making.
• The context of the encounter among all other services previously rendered for the same problem.
• Complexity of documented comorbidities that clearly influenced physician work.
• Physical scope encompassed by the problems (number of physical systems affected by the problems).

Identify all the presenting complaint(s) and/or reason(s) for the visit for which physician work occurred:

• Demonstrate clearly the history, physical and extent of medical decision-making associated with each problem.
• Demonstrate clearly how physician work (expressed in terms of mental effort, physical effort, time spent and risk to the patient) was affected by comorbidities or chronic problems listed.

Using the Trailblazer guidance, teach physicians that the standard of documentation is the assessment with the plan right next to it. The physician will be making a conscious, concerted effort to document relevant clinical concerns, including patient risk factors and other clinical elements. These are all instrumental in establishing medical necessity for admission through explicit and easily inferred clinical judgment. For example:

Assessment: Concern with acute renal failure. Patient was found on the ground, broke her hip and couldn’t get up for two days. BUN and creatinine are 40/2.6. Patient not producing urine.

Plan: Starting patient on 1L bolus of fluid and continue down to 250ccs/hour. Strict measurement of ins and outs.

The above documentation can be taken right out of a medical record and placed into a RAC appeals letter. But if the doctor just writes “acute renal failure—hydrate the patient,” the result is a weaker record that allows less room for appeal.

CDI specialists should be able to look through the record, find the missing diagnoses, talk to the doctor about it, and tell them how providing this documentation improves their practice of medicine. CDI specialists should review the record in its totality.

Some good news for CDI specialists in their battle to engage physicians in documentation buy-in: The days of separate hospital and physician payment may be numbered. The writing is on the wall for a closer alignment between physician and hospital payment. Take a look at this pilot project of 12 New Jersey hospitals and their participating physicians. Called “gainsharing,” the program offers physicians financial incentives to work with hospitals in lowering costs in a variety of ways. The program also includes stringent quality controls to protect patients, according to the press release.