Severity of illness: What is it all about and what does it mean for physician profiles, public perception?

Association of Clinical Documentation Improvement Specialists, July 9, 2008

by Robert S. Gold, MD

Dear colleagues:

In the past several years, hospital staffs and insurance companies have bombarded all of us with medical necessity questions. Well, there’s a new sheriff in town, and its name is severity of illness (SOI). It describes the seriousness of our patients’ illnesses and the risk of adverse outcome to treatment choices.

Understanding risk stratification

We may think of risk stratification as one way of determining which antibiotics to prescribe under certain circumstances. Or it may refer to whether a patient is a candidate for surgery, chemotherapy, or any other type of treatment. The Society of Thoracic Surgeons has produced a methodology for developing an SOI database so that its members can level the playing field and compare data with respect to mortality from chest cases. The National Surgical Quality Improvement Project (NSQIP) of the American College of Surgeons is doing likewise. Pediatrics, OB/GYN, cardiology, and other specialties also have been developing methods of tracking SOI standards to determine best practice patterns for patients in our care.

Understanding SOI reimbursement methodology

This information provides a baseline for understanding that physician reimbursement for services rendered—whether it be medical or surgical, interventional or noninterventional, inpatient or outpatient—is becoming an SOI-dependent entity.

Our failure to understand the effects of SOI may decrease our revenue in the future. Physician practices—single-specialty or mixed—that can better document statistics than those of nearby competitors can advertise this information to gain a business advantage.

These physicians can then negotiate more attractive rates with insurers that aim to attract physicians who will help them sell more policies.

Standing out in a competitive market

Hospitals that demonstrate to the press, the overseers, and the community that they have the best performance level in certain areas will survive in competitive markets.

Hospitals can do this only if their physicians can demonstrate that they’re the best. The motto, “If you don’t look good, we don’t look good,” says it all. For example, one hospital recently lost its heart transplant accreditation because it couldn’t attract sufficient volume to maintain its practice when a competitor advertised its own five-star rating in heart surgery.

Considering noncompliant situations

Let’s consider some situations as they may pertain to physicians.

An internist who sees patients in the hospital, nursing home, or office probably sends bills for patient visits—including admissions, subsequent visits, discharges, and consultations—to insurance companies and Medicare.

An internist who submits bills with diagnoses whose corresponding codes are obsolete or don’t demonstrate that the patient is sick or complex minimizes potential reimbursement and value for that visit.

For example, an internist sees a patient with diabetes and reports ICD-9 code 250, which doesn’t exist. This does not yield payment. However, if the internist submits code 250.00 which indicates that the patient has type 2 diabetes and is otherwise fine, this will yield payment.

Increasing awareness

When internists are not aware of the various fourth-digit classifications (e.g., retinopathy, nephropathy, autonomic neuropathy, vascular disease, and diabetic ulcers), and the fifth-digit classification that signifies uncontrolled diabetes, coding will improperly reflect that all diabetic patients with type 2 diabetes are healthy.

Internists who report incorrect or nonspecific diagnosis codes minimize the SOI of the diabetes population. A hospital superbill that references all appropriate choices, including the myriad of diabetes conditions that are neither type 1 nor type 2, will increase SOI and complexity of medical decision-making.

Similarly, when a pulmonologist who sees patients with chronic respiratory failure—regardless of the cause—is unaware of the diagnosis and code for chronic respiratory failure (code 518.83), all chronic obstructive pulmonary disease patients (code 496) and all deformity patients and pulmonary fibrosis patients will appear to be healthy.

If a surgeon or interventionalist’s documentation is incomplete or nonspecific, then all of the hospital’s complex patients with multiple comorbid conditions, various organ failures, or increased risk factors ranging from malnutrition to morbid obesity or immunosuppression will appear to be healthy.

Avoiding adverse outcomes

Any adverse outcome is totally unacceptable in any of these situations. When physicians and hospitals share patient payments for inpatient stays, our portion will be less than it should be, unlike our colleagues whose thorough and accurate documentation ensures proper code assignment that demonstrates their patients are truly sick. The ICD-9 code sets make apparent the relationship between our documentation in the medical record and the SOI.

If a physician’s superbill lacks current ICD-9 codes or codes that demonstrate a patient is sick, he or she will not do as well as a physician who is more up to date.

We can obtain this information from our neighborhood hospital coders. They just might make time to review the superbill, speak with the office manager, and make some very valuable recommendations that will make everyone’s life easier now and in the future.


Robert S. Gold, MD

Editor’s note: Dr. Gold founded DCBA, Inc., in Atlanta, a consulting firm that provides physician-to-physician programs in clinical documentation improvement. The goals are data accuracy, profile management, and compliance in the inpatient or outpatient arenas. Contact him by phone at 770/216-9691 or by e-mail at DCBAInc@cs.com.