CHICAGO – Hospitals seem to be adjusting to the need for more specific coding by moving that responsibility to interdisciplinary processes and adopting clinical documentation improvement programs.
The bar was raised for coders this past October, when the Centers for Medicare & Medicaid Services began phasing in a severity-adjusted payment system called Medicare Severity-adjusted Diagnostic Related Groups, or MS-DRGs. The new approach bases reimbursement for care on whether patients have major co-morbidities or complications.
CMS expects to fully transition to the severity-adjusted payment system on October 1, 2008 for fiscal year 2009.
In addition, hospitals now are submitting claims with a “present on admission” code to better document patients’ conditions at the start of the care process. The POA code is intended to help identify secondary diagnoses that were not present at the time of admission.
Hospitals began submitting POA indicator information for all primary and secondary diagnoses last October 1. Starting January 1, CMS expects to begin reporting on remittance advice errors related to POA indicator assignment. After April 1, CMS intends to return claims that do not contain proper reporting of the POA indicator.
Coding professionals at hospitals are encountering new challenges under the MS-DRG approach, mostly related to the need for specificity in documenting conditions and care. In many cases, submitted documentation is conflicting, non-specific or missing, said Carol Spencer, manager of professional practice resources for the American Health Information Management Association. The need for more specific documentation typically results in a physician query.
Because of the increase in physician queries and the need for more specific, timely and complete documentation at the time of care, hospitals are implementing concurrent clinical documentation improvement programs, which may reduce the need for retrospective queries.
“Moving the query process to a concurrent process supports a healthy revenue cycle and avoids delays in claim submission,” Spencer said. “Retrospective queries stop the accounts receivable process. The challenge lies with balancing the need for quality coded data and meeting accounts receivable targets.”
The diagnosis causing the biggest confusion under the switch to the new system has involved coding congestive heart failure, unspecified as a secondary diagnosis. Spencer said care documentation often is not specific enough to code care as more severe cases, qualifying for bigger reimbursement.
To improve the quality of coding, more hospitals have adopted clinical documentation improvement programs, which aim to improve the capture of clinical documentation at the point of care, improve case mix, reimbursement and compliance and reduce denials in an environment more conducive to real-time communication. “For the most part, physicians are embracing such efforts because they increase efficiency and eliminate the need for retrospective queries,” Spencer said.
“Coding is becoming more of a team approach in which clinical and coding staffs are working together concurrently to achieve the specificity required in documentation,” she said. Such efforts will become even more important because claims information, which reports coded data, is increasingly used to assess patient care quality.