It’s the rare hospital that has never experienced delays in receiving reimbursement as a result of clinical documentation coding snafus. But it’s also likely that most hospitals, even if they receive payment in a timely manner, don’t realize true financial compensation based on patients’ actual condition and treatment, thanks mostly to glitches or gaps in coding.
“It’s amazing how many times I’ve seen records where the discharge diagnosis, for example, says only ‘cellulitis,’ but the patient spent three days in the ICU being treated for sepsis,” said Anthony Oliva, MD, national medical director with healthcare compliance and clinical documentation improvement company J.A. Thomas & Associates, part of Nuance Communications. But, since the physician didn’t use such language in his records, clinical coders couldn’t translate that information into diagnostic codes for billing. The result: “The reimbursement isn’t even going to be close to what the cost was,” Oliva said.
Hospitals that don’t make a serious stab at clinical documentation improvement (CDI) will be poised to take an even harder hit come October 2015, the start date for ICD-10 implementation. “A major issue will be hospitals coding procedures on in-patient accounts with procedure codes for ICD-10-PCS,” said Angie Comfort, senior director of HIM practice excellence at The American Health Information Management Association (AHIMA). ICD-9-CM at least accommodates unspecified coding for billing when physicians fail to fully document something, such as exactly what type of device they may have used for a patient procedure or the type of congestive heart failure a patient suffered.
With ICD-10-PCS, she says, “if a physician doesn’t document everything that’s used for a procedure, the hospital can’t bill for it even under an unspecified code.” That’s because unspecified codes don’t exist in ICD-10-PCS. And, Oliva added, “as we start to talk about pay for quality and value- based purchasing, [accurate clinical documentation] becomes even more important. If we are not describing the severity of the patient case accurately, the cost of caring for the patient will be under-recognized.”
Prepping for better results The good news is that over the last decade or so, most large facilities, and some smaller ones, have put in place some CDI effort, even if not a formal program, according to Comfort. She doubts that CDI would have experienced such a take-off unless hospitals were realizing some positive reimbursement results.
But there’s always room for improvement, not only to help with timely and on-point reimbursement, but also to ensure that patients’ health records are complete and accurate. In fact, the latter argument may resonate better with physicians to some extent, especially those that have followed the same documentation patterns for decades and are resistant to change, Comfort noted.
If we are not describing the severity of the patient case accurately, the cost of caring for the patient will be under-recognized.
Another way to persuade doctors to improve clinical documentation is to relate it to physician scorecards and profiling, Oliva said. Physicians who don’t use the right words to describe the severity of patients’ illnesses can be cast in a poor light when patient outcomes are negative, particularly if those results are compared to the positive experiences other physicians have with similarly described patients, but who were not truly as ill. “It’s a real problem for them if their patients don’t look that sick on paper, but wind up in the hospital for eight days versus two or even die,” he said.
Making CDI work means ensuring that CDI specialists who engage with physicians state the case for accurate and quality documentation simply, and “make sure they understand what we are asking them to change or update in their documentation,” Comfort explained. And, having in place a physician champion to encourage colleagues’ support of the effort “is one of the most important parts of having a successful CDI program,” she said.
Having trained nurses review the documentation, identify issues and engage the physician in the clarification process is the foundation of J.A. Thomas’ approach, Oliva said. But there are increasing opportunities to streamline and automate tasks. For instance, Nuance’s natural language processing and analytics technology can pull out words in physicians’ documentation that can suggest to reviewing nurses the presence of certain conditions that may not have been reported, but should be coded for billing purposes.
For example, the physician may have noted that a patient has pneumonia, an elevated white blood cell count, a fever over 102, and is receiving a certain type of medication – factors that when present together indicate the patient may have sepsis, even if the doctor neglected to write sepsis in her notes.
It also is possible, Oliva said, to begin using EMRs with natural language processing technology and clinical strategies to offer doctors clarifications of what they may want to state in their notes (either through speech or text input) in real-time, without disrupting workflows.
There’s no denying that the potential for improvement exists.
“We say we have CDI, but there is still four to six percent of case-mix index opportunity that many hospitals could be capturing, but they’re not because they don’t have a comprehensive, clinically-based program,” Oliva said. “I truly believe that CDI done in a comprehensive way helps hospitals in the transition from a fee-for-service model to a pay-for-value, or pay-for-quality, model. It can optimize the revenue they deserve for the resources utilized to care for the patient now, and better identify the severity of the patient for appropriate risk adjustment.”