Health Information Management

Scrutinize documentation in 2012 and beyond

JustCoding News: Inpatient, February 29, 2012

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Even if you don't make a personal New Year's resolution, you should make a professional one: to be more conscientious when scrutinizing physician documentation.

Experts say every coder should scrutinize physician documentation, especially with ICD-10-CM/PCS looming on the horizon. Focusing on documentation also facilitates preparation for the onslaught of third-party auditors that may knock on facility doors during the coming year.

"Coders should really be validating the entirety of the documentation," says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent health information management (HIM) consultant in Madison, WI. "Coders will push back on this, but I'm tired of hearing that. We're not questioning doctors' clinical judgment or medical decision-making; we're questioning the documentation in the record. There's a difference."

Look beyond the words

What role should coders play in determining diagnosis quality and accuracy? A significant one, says Krauss.

Simply validating that a DRG has been assigned correctly based on the physician's documentation of a principal diagnosis is not sufficient. Coders need to actually review documentation to determine whether the diagnosis that drives a particular DRG is justified, he says. This review should exceed any conclusionary statements in the discharge summary and include a careful examination of any and all progress notes and the history and physical, Krauss says.

Coders should consider the following questions:

  • Does documentation support the diagnosis? For example, does documentation clearly include the patient's status, responsiveness to treatment over time, or any relevant laboratory results that help establish the validity of the diagnosis?
  • Is the diagnosis mentioned more than once?
  • Does nursing documentation support physician documentation of the diagnosis?

The July 2011 Medicare Quarterly Provider Compliance Newsletter indicates that recovery audit contractors (RAC) are specifically questioning the validity of acute respiratory failure. “After physician and auditor review, it was determined that the clinical evidence in the medical record did not support respiratory failure, despite physician documentation of the condition,” CMS says in the newsletter.

The updated RAC Statement of Work released September 1, 2011, distinguishes between DRG validation and clinical validation. In this document, CMS says RAC auditors will validate DRGs and determine whether patients truly possessed conditions that physicians documented. Consider the following excerpt from p. 23:

DRG validation is the process of reviewing physician documentation and determining whether the correct codes, and sequencing were applied to the billing of the claim. This type of review shall be performed by a certified coder. For DRG validations, certified coders shall ensure they are not looking beyond what is documented by the physician, and are not making determinations that are not consistent with the guidance in Coding Clinic. Clinical validation is a separate process, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented. Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder. This type of review can only be performed by a clinician or may be performed by a clinician with approved coding credentials.

"The MAC, RAC, and CERT contractors are second-guessing physicians, saying [these diagnoses] aren't there," says Krauss. He has seen similar denials for observation, MS-DRGs 981-983 (OR procedures unrelated to principal diagnosis with MCC, with CC, and without CC/MCC), MS-DRGs 947–948 (signs and symptoms with and without MCC), and MS-DRGs 949-950 (aftercare with and without CC/MCC).

If coders determine that documentation doesn't support diagnoses, they should notify a physician advisor or medical director, says Krauss. Advisors or directors should speak directly with physicians whose documentation is in question. Hospitals should develop policies and procedures that require coders to notify a physician advisor and describe the process for doing so, he says.

Focus on DRGs with one MCC

Pay close attention to records that include only one MCC, says Krauss. The October 2011 Medicare Quarterly Provider Compliance Newsletter addresses several denials related to the invalidation and removal of MCCs. For example, one scenario involves the removal of ICD-9-CM code 518.4 (acute edema of lung, unspecified)—an MCC—which changes the MS-DRG from 235 (coronary bypass without cardiac cath with MCC) to MS-DRG 236 (coronary bypass without cardiac cath without MCC). Another example involves the removal of ICD-9-CM code 518.5 (pulmonary insufficiency following trauma and surgery) —also an MCC—which also changes the MS-DRG from 235 to 236. A third example involves the removal of ICD-9-CM code 434.91 (cerebral artery occlusion, unspecified; with cerebral infarction) —an MCC—which changes the MS-DRG from 100 (seizures with MCC) to MS-DRG 101 (seizures without MCC).

Hospitals should generate reports of their top 25 MS-DRGs by frequency and then reduce the list to those with only one MCC, says Krauss. Ensure that documentation supports assignment of that MCC, he says.

Be aware of cloned documentation

In addition to confirming the validity of diagnoses, RACs and other auditors are reviewing documentation from a quality of care perspective. As hospitals transition to EHRs, many auditors are on the lookout for cloned documentation, often a problem in teaching hospitals and large academic medical centers, says Dinh Nguyen, of Healthcare Compliance Solutions, LLC, in Pasadena, CA. "Auditors look for instances when the attending physician cuts and pastes from the resident's note into his own," says Nguyen. The problem also may extend to nursing progress notes, he says.

CMS requires documentation of each encounter so that the note stands on its own and represents the actual services provided by the attending physician for each date of service or encounter. Data, including vital signs, may not be copied from one visit to the next. CMS states that note cloning raises concerns about the medical necessity of continued hospitalization, says Nguyen.

As coders abstract information from the medical record, they should closely examine documentation across multiple dates of service to determine whether it appears to be the same, says Nguyen. When it is, coders should query treating physicians or work with physician advisors to obtain clarification, he says.

"If a patient is in the hospital for four days, the documentation should describe whether the patient's condition is improving, stable, or deteriorating each day over the length of stay in the hospital," says Nguyen. "If the documentation reads the same from days one through four, that would potentially raise a red flag for external auditors. Cloned documentation doesn't meet medical necessity, and it will lead to denials and recoupment of overpayments, according to MAC Palmetto GBA®. Click here to access more information.

Additional audit focus areas

Nguyen and Krauss recommend auditing the following claims, respectively:

  • High-dollar claims, particularly claims that result in payments of more than $10,000, and those with a high-dollar payment threshold and short length of stay in the absence of intensive interventions or procedures.
  • Claims that include low-weighted DRGs with short stays. These are frequent targets because RACs can typically review these records that include minimal documentation (e.g., one progress note, one history and physical, and one discharge summary) very quickly and deny claims based on this information when it doesn't support the admission.

Editor's note: This article was published in the January issue of Briefings on Coding Compliance Strategies. E-mail questions to Managing Editor Doreen V. Bentley, CPC-A, at

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