Health Information Management

Tip: Encourage uncertainty to help alleviate the pain of symptom DRGs

CDI Strategies, February 4, 2010

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The problem
According to a recent poll on the ACDIS Web site, 85% of members cope with physicians who frequently document unspecified chest pain. In addition, 51% of those polled stated that their physicians often fail to respond to requests for clarification. This scenario results in the assignment of symptom MS-DRGs and potential Recovery Audit Contractor (RAC) issues. RACs in the past have denied entire inpatient stays for chest pain as medically unnecessary, arguing that the patient should have been placed in observation.
The problem stems from physician vs. coding speak, according to William Haik, MD, director of DRG Review, Inc., in Fort Walton Beach, FL. “A lot of physicians will say, ‘non-cardiac chest pain,’ and from a physician’s perspective, that means life-threatening cardio-pulmonary illnesses like myocardial infarction and pulmonary embolus have been ruled out,” Haik says. “Physicians frequently don’t know what causes the chest pain in the short time the patient is in the hospital.”
Because physicians often feel pressured to get patients out of the hospital quickly, they plan to work up these patients’ other non- cardio-pulmonary problems (e.g., gastrointestinal, musculoskeletal) on an outpatient basis, but fail to provide documentation in the record. Many physicians assume that this further treatment does not need to be documented, whereas from the CDI specialists’ perspective it’s frequently the missing piece.
“When we say ‘chest pain non-cardiac,’ we’re telling people it’s okay to send the patient home, and the reason we admitted them was for fear of acute cardio-pulmonary disease,” Haik says. As “physician speak” this line of thinking makes sense, Haik adds, but it presents a problem for coders.
The solution
CDI specialists can combat this problem by asking physicians to specify uncertain diagnoses in the medical record, using terms like ‘probable,’ ‘suspected,’ or ‘still to be ruled out’ at the time of discharge, Haik says.
“Ask physicians to document their best likelihood of the illness, based on present treatment or plans for outpatient evaluation, and as long as there’s supporting documentation in the medical record,” he says.
For example, if a physician rules out cardiopulmonary disease, and places the patient on Prilosec ®, and plans to perform an outpatient endoscopy later on, it justifies querying the physician for a diagnosis of gastritis, still to be ruled out. “I always tell physicians to document what they think, based on their clinical acumen,” Haik says, adding with humor that it’s their “one chance to play doctor.”
This can be a difficult sell as physicians are taught to document to the highest degree of certainty, but not to document uncertainty in the medical record. “If someone comes in my office 15 times with a headache, I have to say ‘headache’—I can’t document ‘probable brain tumor’ until I know they have a brain tumor,” Haik says.
But the ICD-9-CM inpatient coding rules work the opposite way.
Haik says that CDI specialists can use the following points to help teach physicians to document uncertain diagnoses like chest pain:
  • chest pain is an area of RAC focus, and admission denials due to chest pain may be viewed as an unnecessary hospitalization and hurt the physician’s profile
  • chest pain has a low severity, and using hospital resources for a low-severity patient paints a picture of low-quality of care, and a lower-quality physician

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