Health Information Management

Physician engagement in three ?easy? steps

CDI Strategies, May 12, 2016

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It’s an age-old question: How do you get physicians to support documentation improvement efforts?

“I first spoke on this topic 26 years ago,” says William Haik, MD, FCCP, director of DRG Review, Inc., in Fort Walton Beach, Florida. “The same points I might have made then are still important, but Medicare keeps giving us additional reasons to make sure the documentation is as specific as possible.”

In the 1980s, when Haik first started practicing as a pulmonologist, he was the only one in his county, so hospitals and other physicians sent their sickest patients to him for treatment. One “sunny Sunday,” as he puts it, the local paper decided to rank hospitals against each other using the region’s outcomes for pneumonia patients.

“I’d scribble ‘pneumonia’ on the discharge summary and not think any more about it,” says Haik of his former self. “I knew they had multiple comorbid conditions and that they needed more expensive antibiotic treatments, but I didn’t understand how my documentation depicted my patients’ conditions to the outside world.”

That changed in a hurry: The newspaper’s report made it appear as if Haik’s patients were twice as likely to expire from pneumonia than patients at any other facility in the county.

“I knew I wasn’t God’s gift to medicine, but I also knew I wasn’t that bad,” he jokes. Haik began to learn all he could about the payment and coding systems, studied the common lack of congruence between coding language and the clinical world, and approached the AHA Coding Clinic for ICD-9-CM editorial board with discrepancies. They invited him to join the board.

Although no longer a Coding Clinic editorial board member, Haik continues his private practice and lectures on the importance of documentation improvement around the country. Physician support of CDI efforts, he says, depends on “the three P’s: profiles, physician payment, and patient care.”

Once upon a time, when someone wanted to determine who was a good physician, he or she would depend on the advice of family or friends, or that of the larger community, says Haik. Today, good physicians are determined by the hospital length of stay (LOS) for their patients, cost efficiency for treating a given patient or population, and quality parameters set by the government.

“And all of this depends on the codes assigned. And that,” says Haik, “depends on the documentation.”

Physician payment
Physicians receive payment based on how much time and clinical decision- making their patients need for effective treatment. To assess this, physicians complete a number of medical record components—the family history, history of present illness, review of systems, etc.—which correspond to a variety of evaluation and management (E/M) codes. The codes are stratified so the more time and medical consideration a particular patient or situation requires, the more the physician is paid for the associated care.

A patient with bronchitis doesn’t require a lot of care, so a physician would report the lowest E/M code, says Haik. But if the patient has bronchitis and COPD, then the physician gets to report a higher-level code. If the patient suffers from bronchitis and COPD and has acute respiratory failure—and all the documentation supports these diagnoses— the physician can report the highest level of E/M code and get paid commensurate with the clinical effort involved for that patient’s care, says Haik.

However, “if I don’t say the magic words and get credited for those codes, it goes back to the lower level of care, and the physician suffers all the consequences that entails,” he says—including possible public shaming such as the kind Haik endured in the early ‘80s.

Payment methods have become more and more complicated over the years, he says. The Affordable Care Act includes cost efficiency measures that effectively penalize high-cost/low-quality care providers by up to 2% of reimbursement. Additionally, Hierarchical Condition Categories (essentially a coding stratification system similar to MS-DRGs) aggregate patients with similar conditions and assess payments based on how efficiently a provider treats that group. Efficacy within norms equates to a normal payment, below average equates to a less-than-optimal payment, and above average equates to higher reimbursement.

“If the provider only documents diabetes but the costs for treatment are higher than other providers’ costs, that physician will receive less reimbursement,” says Haik. “If that same patient also has neuropathy related to the diabetes, that patient is expected to need more resources, and payment will reflect that. The documentation matters.”

Patient care
The documentation included in a patient’s medical record (and the codes assigned to reflect that documentation) travels with the patient throughout his or her medical care. The data is then aggregated by any number of private and government agencies and used for population health assessment, research, and changes in payment methods.

Physicians want to provide patients with the best care possible, Haik says, but without precise documentation, the data will not reflect that care. CDI professionals seeking to win provider support need to underline that point.

“Bottom line, I believe that the physician is the very first, and last, patient advocate. Part of our advocacy role is to make sure that our patients get the appropriate level of resources directed to their specific healthcare needs,” says Haik. “The only way to do that is through complete and specific documentation to accurately reflect the level of severity of the patient’s illness. And that’s really why documentation is so important.”

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