Case Management

Mentor moment: Communicating with physicians is the key to effective case management

Case Management Weekly, June 15, 2011

By Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS

In my last blog post, I focused on key clinical documentation provisions that help physicians demonstrate medical necessity for the admission.

Allow me to share a recent experience I had with a physician group regarding clinical documentation, which demonstrates the value in engaging physicians in a dialogue about the merits of clinical documentation.

Two months ago, I met with a group of hospital case managers. During that meeting, we discussed working with physicians to establish medical necessity for inpatient admission and continued stay. I asked the case managers their process for communicating with physicians when a patient does not meet screening criteria for a hospital admission or a continued stay. The resounding answer from the group was that the case manager leaves a note for the physician asking him or her to document medical necessity, order observation services, or discharge the patient.

The next day I met with the hospital’s cardiologist group to discus documentation shortfalls I recognized after reviewing their inpatient records. I asked how they typically respond to the case managers’ notes. They answered that they generally ignore the notes because they do not know what constitutes medical necessity. They said if they knew what accounts for medical necessity they would be sure to include the elements in the documentation.

I shared this information with the case manager group. I told them the cardiologists would be willing participants in the documentation process if given the opportunity to learn what constitutes medical necessity. This was a revelation to the case managers. They assumed the physicians knew what constituted medical necessity.

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