Tip: Get physicians on board by providing CERT education
CDI Strategies, July 24, 2008
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Solidify evidence of medical decision-making in the record
If you’re looking to help achieve CDI buy-in with the physicians in your hospital, look no further than the Comprehensive Error Rate Testing (CERT) program, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, senior coding and chargemaster consultant with QHR in Brentwood, TN. The CERT program not only examines physicians’ evaluation and management (E/M) payments, but it also shows the percentage of E/M claims by type that had insufficient documentation to support billing. You can tie the physician’s E/M payments to the hospital’s MS-DRG reimbursement by focusing on diagnoses that serve as common ground between the two separate payment systems, Krauss says.
A common problem with physician documentation is that physicians don’t repeatedly document certain diagnoses during subsequent visits. This leads to errors with billing for subsequent hospital care (e.g., codes 99232 and 99233). For example, a physician documents “acute bacterial pneumonia, suspected staph” on the first visit. But he or she does not report any diagnosis on his subsequent notes. Instead, the notes simply state “Patient doing better,” “Patient stable, no new complaints,” or “Patient looks okay, nursing notes noted, process as planned.”
When this is the case, provide education to the physician so that he or she understands the importance of documenting all relevant diagnoses. Use Table 4b (Top 20 Services with Insufficient Documentation) from the CERT report when offering this education, Krauss says. Or, if the physician is too busy, offer to go over the results of the report with the physician’s practice manager during lunch. The report contains some easy-to-read charts that you can quickly review, he adds. “Tell the physician, ‘Thanks for being so diligent with your query. Let me provide you with a tip that will keep you compliant with Medicare regulations and let you keep your money,’” Krauss says.
The following link to the CMS Web site takes you to the CERT report, which includes tables of the top 20 coding errors and the top 20 insufficient documentation errors. Click “findings” on the left hand side.
The most critical piece of the report for CDI specialists’ purposes is “Insufficient Documentation Errors,” which the report defines as follows:
Insufficient documentation means that the provider did not include pertinent patient facts (e.g., the patient’s overall condition, diagnosis, and extent of services performed) in the medical record documentation submitted. In several cases of insufficient documentation, it was clear that Medicare beneficiaries received services, but the physician’s orders or documentation supporting the beneficiary’s medical condition were incomplete.
“The bottom line is that the physician didn’t provide diagnoses for the E/M he billed,” says Krauss, of the CERT report findings.
Alleviate physician frustration by telling physicians that chronic/stable conditions in the patient’s history and physical don’t have to be rewritten each and every day of the hospitalization. Physicians are only required to document those conditions that are acute, have become acute, or are worsening. Advise physicians to focus on documenting their concerns about a diagnosis. For example: Klebsiella pneumonia, improving, with IV of Cefepime, noted white count of 12, X-ray clearing, start PO antibiotics, anticipate discharge when temperature falls to 100.
When a patient with chronic stable congestive heart failure (CHF) and pneumonia receives IV Lasix (R) during the stay, ask the physician to explain its significance. When appropriate, ask him or her to document whether the CHF is an acute exacerbation of chronic CHF, and if known, left- or right-sided, systolic versus diastolic, or both.
A new reportable diagnosis potentially affects both the MS-DRG assignment and helps to support a more appropriate level subsequent hospital care E/M code for the physician. “This practice also helps defend against Recovery Audit Contractor audits and their arbitrary rules of medical necessity by demonstrating medical necessity and clinically supporting the necessity of inpatient stays,” Krauss says.
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