Health Information Management

Tip: Start with emergency room documentation to help reduce claims denials

CDI Strategies, July 5, 2012

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Broaden the scope of your CDI efforts by looking for medical necessity indicators and increasing proactive efforts to reduce audit risks.
CDI specialists can increase their value to their hospital and ensure a far greater degree of physician buy-in by serving as a pro-active denials management specialist. In some respects CDI specialists already serve as denials avoidance agents, playing an active role in changing patterns of physician documentation to reduce the likelihood of medical necessity denials.
A major role of the CDI specialist is to ensure proof of medical necessity. This does not necessarily mean that CDI specialists should become quasi-case managers. However you cannot perform CDI in a vacuum, either. Getting a physician to document a diagnosis through a query without obtaining supporting documentation (including an accurate picture of patient’s history of present illness, physical findings, abnormal lab and radiology tests, and the physician’s clinical judgment and medical decision-making used to determine the diagnosis or differential diagnoses) will likely result in a denial, and a takeback of the diagnosis by an auditor.
Therefore, what CDI specialists should focus upon is obtaining documentation in the history and physical (H&P) to support the severity of the patient’s signs and symptoms. The H&P must demonstrate the patient’s risk of mortality and the likelihood of an untoward event. Each H&P should contain:
  • A chief complaint that reflects the patient’s true chief complaint. This does not mean a definitive diagnosis like stroke, pneumonia, or sepsis (have you ever heard of a patient who comes in and says they have sepsis?). The chief complaint is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. What is the patient’s problem, in the patient’s own words? Examples include “patient complains of upset stomach, aching joints, and fatigue.” In general the medical record should clearly describe the chief complaint and nature of patient’s presenting problem.
  • The patient’s associated signs and symptoms. The amount and complexity of comorbid conditions reflect the additional amount of physician work performed in managing these conditions.
  • A history of present illness (HPI) with at least four elements. There should be a direct correlation between the HPI and the assessment. You should be able to trace back the physician’s assessment and impression outlining clinical diagnoses and plan of care to the patient’s presentation and nature of presenting problem as described in detail within the HPI. The documentation should clearly paint the picture of the patient’s severity of illness and necessary intensity of service.
Recovery Auditors are not just checking for accurate coding but validating diagnoses for clinical reasonableness. Consider if a physician provides the following documentation in his or her assessment of a patient with likely sepsis:
Patient had a temperature of 103 degrees with a white count of 20 with 10 bands. Initially patient seen in my office last week with subjective fever, chills, and general malaise. Prescribe course of antibiotics but now presents to the emergency room with worsening cough, fever, weakness, somewhat change in mental status from her baseline of mild dementia. Patient looks like he has a UTI from the urinalysis in the ED, likely has sepsis with potential pneumonia with a positive chest x-ray. Will need a course of IV antibiotics due to failure of outpatient antibiotic treatment to see if we can prevent a re-occurrence of previous hospital admission four months ago where patient developed a deep seated UTI with sepsis that was resistant to IV antibiotic treatment and had a rocky course in the hospital.
Are you going to question the medical necessity of the admission? It’s also far less likely that a Recovery Auditor or other Medicare contractor will second-guess the physician’s clinical judgment in determining the appropriateness of inpatient admission versus observation.
Here are some more tips to consider when performing your record reviews:
  • Review the entire record. Start with the ED notes from the time the patient arrived in the ambulance to see what brought him or her to the hospital. Review the H&P to make sure the physician documented that the patient was truly sick (watch out for “point and click” electronic documentation prompts, as these don’t provide evidence of the doctor’s medical decision-making). We need to be able to tell physicians to come up with a couple sentences that captures their thought processes as to how they came up with the diagnosis.
  • Wear your nursing hat. Do you see a sick patient? If you don’t see a sick patient in the documentation, ask what is missing. Is the HPI deficient? Is the physical exam not thorough? Is the past, family, and social history (PFSH) not thorough? If a physician is thinking myocardial infarction (MI) in a 55-year-old Medicare patient with chest pain, and the patient has a strong family history of early MI, that certainly changes the picture.
  • Educate your physicians one-on-one. If you review the nursing notes and see that a patient was breathing 40 times per minute and was so short of breath that he couldn’t walk across the room, and upon arrival at the hospital his P02 was 45 and PC02 was 60, with a ph of 7.25, but the doctor writes in his H&P “patient seen in the exam in no apparent distress,” that’s a good place for one-on-one education.
    Tell the physician, “I looked at the ED documentation and it looks like a different patient between yours and the ED physician’s. What are your thoughts on how sick the patient was?” The physician should be writing, “The patient is not in respiratory distress at this time, but presented in obvious respiratory failure upon presentation to the ED.” The patient may not be in respiratory failure now, but he certainly was, and that’s of concern to the physician and reflects part of his or her medical decision making in admitting the patient to the hospital for close workup and further management.
Remember that CDI is intended to represent Clinical Documentation Improvement—improving documentation of the patient’s clinical picture throughout the record—and not strictly RDI (Reimbursement Documentation Improvement). In this day and age of the Recovery Auditors, obtaining documentation for diagnoses alone simply isn’t enough.
Editor’s Note: Krauss is an independent HIM and CDI consultant based in Madison, WI. This article first published on the ACDIS Blog, Helping the physician and the hospital through proactive denials management. Join Krauss and Shailesh R. Virani, MD, for the July 17 webinar “Outpatient CDI: A Proactive Approachto Denials Management.”

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