The physician advisor: An invaluable resource
If your facility does not have a physician advisor, my recommendation is to get one. The physician advisor at our facility is great. Dr. Jim Chambers is very knowledgeable, not only in the field of cardiology, but he is quite knowledgeable in the area of coding. Dr. Chambers has spend countless hours educating and assisting our hospital billing department in establishing correct billing codes.
Documentation is key in obtaining the appropriate billing code. Physicians work hard taking great care of their patients, but what they lack is being able to document everything they have done for the patient and the outcomes. Outcomes are essential in the world of coding. For example, when a patient comes in with an abnormal prealbumin level, the physician treats this, but yet sometimes only documents that the patient has malnutrition. In this case, the hospital is reimbursed at the lowest level for malnutrition.
The stages of malnutrition are based on the prealbumin level, so the physician needs to document what level of malnutrition the patient is experiencing as there is dollar difference in the different levels of malnutrition. Our physician advisor has been working with our physicians to correct this.
Another area of clarification that has been established through our physician advisor is clarification of heart failure. What type of heart failure does the patient have? Is it acute or chronic, left or right, and systolic or diastolic? Our physician advisor has worked diligently with our physicians so they have appropriate documentation to support the diagnosis.
Over time, our physicians have improved significantly with their documentation. Through the education provided by our physician advisor to our case management team, the case management team developed a standardized note that we have made into sticky notes that we can leave our physicians to remind them to make sure they address VTE, if the patient needs any therapies, to distinguish and document the type of heart failure and what stage of malnutrition a patient is at. This note also addresses present on admission. This reminder note is a valuable tool in reemphasizing the need for complete, thorough, and accurate documentation.
Our physician advisor is our secondary medical reviewer in our InterQual process. This is great because if he does not think the patient meets criteria, he works with our case management team and admitting physician to come to consensus on what is best for the patient. Our physician advisor also attends our interdisciplinary rounds so he is very much aware of the challenges that we face. He is a great resource when discussing patients and we are trying to work through discharge barriers. In talking with Dr. Chambers regarding the key to having a successful physician advisor, his advice is that a facility must have a physician who has strong clinical skills and he/she must also have in-depth knowledge of billing codes and regulations.
Does your facility have a physician advisor? Do you use an outside service? What are the pros and cons?
About the Author: Loretta Olsen, RN, has over twenty-eight years of experience in healthcare, from hospital staff positions to director level positions in various nursing practices, to experience the health insurance arena. She has worked as a product manager in group health insurance overseeing prescription drug plan designs, including implementing Medicare Part D. She also was the contract specialist in implementing disease management programs. She is currently the director of case management at Jennie Edmundson Hospital in Council Bluffs, Iowa. Olsen is pursuing her Masters of Science in Nursing.
