Health Information Management

Tip: Three Rs can improve diagnosis capture, medical necessity documentation

CDI Strategies, April 30, 2009

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CDI specialists should seek to promote the three “Rs” to improve their physicians’ overall documentation habits, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI, senior coding and chargemaster consultant with QHR in Brentwood, TN. These include:
  • Render: The physician should record a comprehensive patient history and physical exam
  • Review: The physician should rationalize and analyze data, including the results of the diagnostic workup, and capture this process in the record
  • Report: The physician should document working clinical diagnoses and his or her impression through use of clinical medical decision-making and clinical judgment
The three “Rs” help with documentation of not only definitive and suspected diagnoses, but medical necessity as well. Medical necessity is especially important to hospitals now that the Recovery Audit Contractor (RAC) program is set for nationwide rollout, Krauss says.
 
The physician’s established working diagnoses and clinical impression must be consistent with patient findings, and the plan of action must be consistent with the patient’s diagnoses, Krauss says. As a CDI specialist reviews the record for completeness and accuracy of the physician’s clinical documentation, he or she should incorporate a process of assessing the documented patient’s chief complaint, the physician’s history of present illness and the physical exam (review of exams) to determine support for the diagnoses made, the plan of treatment, and whether the overall care appears to be medically appropriate.
 
“It’s not just about the buzzwords, it’s about getting the physician’s thoughts down on paper,” Krauss says.
 
To this end, a CDI specialist can serve as an advocate for the physician and patient in demonstrating the severity of illness, providing feedback to the physician on key documentation points and clinical considerations which may be of concern to the physician, but with which he or she has not provided definitive documentation in the patient’s record.
 
Here’s an example to illustrate this point:
A 78-year-old woman is admitted to the hospital with shortness of breath. Her history and physical exam reveal no previous diseases except for a remote history of pulmonary embolism 10 years ago. Her breathing rate is 28 times/minute and her oxygen saturation is down to 74%. The patient received 15 liters oxygen nonrebreather mask as part of respiratory management. However, when attempts were made to wean the patient off oxygen, her saturations dropped below 85%. Workup for MI and pulmonary embolism ensued. The workup for pulmonary embolism revealed a strong clinical likelihood for emphysema and pulmonary hypertension (the patient had significant exposure to second hand smoke from her husband).
 
The physician noted the results of the abnormal diagnostic tests in the record but did not explicitly document the clinical significance or cause and effect relationship between the hypoxemia and the possible clinical diagnoses suggested. The physician wished to perform a pulmonary function test to determine the status capacity of the lungs and perform an echo to determine the status of the heart and any possible heart disease. The patient and family refused further patient workup and she was subsequently discharged home on home oxygen. The final diagnoses as listed in the discharge summary appeared as follows:
·        Hypoxemia
·        Emphysema
·        Hypertension
·        Senile dementia
·        Depressive disorder
           
Because the emergency physician didn’t tie the diagnoses of pulmonary hypertension or emphysema to the patient’s initial symptoms, the coder eventually had to report hypoxemia as the primary diagnosis, resulting in a DRG assignment of 208 (Other Respiratory System Diagnoses without MCC) for a two-day stay—a sure target for a RAC contractor, Krauss says. In this case, the absence of the third “R” was the culprit. A good CDI specialist should work with the physician to get him to relate his clinical impression to the symptomology.
 
Good documentation starts in the ED and the patient’s history and physical, “not fishing for a diagnosis from the progress notes,” Krauss says. “The real role of the documentation specialist is to get the record to speak for itself, beyond the context of diagnoses.”
 
He also recommends that CDI specialists raise their core competencies and knowledge base in medical necessity, working in collaboration with the case manager to create a synergistic process. This ensures clinical documentation in support of medical necessity for admission and continued stay in the hospital, Krauss says.



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