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Hospitalist documentation Q&A

Hospitalist Leadership Connection, January 6, 2009

The Centers for Medicare & Medicaid Services (CMS) overhauled its system of MS-DRG hospital reimbursement. Effective on Oct. 1, 2008, CMS ceases to pay hospitals for certain “never events,” including hospital-acquired conditions (HAC) with adjustments to present-on-admission (POA) conditions. The POA Indicator and HAC payment provision apply to Inpatient Prospective Payment System (IPPS) hospitals. Hospitalists should document ways that capture the true severity of illness and quality of care, according to Betty Brown Bibbins, MD, FACOG, CHC, C-CDI, CPEHR, CPHIT, president, chief medical officer, and lead educational consultant at DocuComp, LLC and physician consultant for clinical documentation improvement at Precyse Solutions, LLC.

Q: Can the physician write the ICD-9 in the progress notes?

A: That limits you. Yes, you can, but your HIM coder may have other diagnosis in there that could impact the severity of illness. When you write those numbers, you are limiting yourself. Let the professionals do their job. As physicians, we should document appropriate care. Let the coders do the coding because there are lots of rules and regulations that we, as physicians, might not know that could override even when we code ourselves.

The above excerpt is adapted from Critical Documentation Updates for Hospitalists: Position Your Practice to Maximize Value, a Webcast by HCPro, Inc. in partnership with the Society of Hospital Medicine, aired on Oct. 30, 2008. You can purchase a CD on HCMarketplace.

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