Here are five tips to ensure better documentation and, along with it, better patient care and improved reimbursement.
1. Do Provide Full Diagnosis Detail
Inpatient hospital claims are reimbursed solely on the reporting of codes from ICD-9-CM. The MS-DRG reimbursement methodology groups medical conditions by severity, to include co-existing complications and co-morbidities that either require physician management or affect the physician’s management during the admission. Complication and co-morbidities are defined further as either “standard” or “major.” Greater severity equals a greater level of care, which yields greater reimbursement. When the record is unclear as to the degree of impairment, the coder may not be able to capture the code level that will equate to a higher reimbursement for the hospital.
The common condition congestive heart failure provides a good example of how poorly-defined physician statements may reduce expected hospital reimbursement. Congestive heart failure not further defined does not equate to a complication or co-morbidity for MS-DRG reimbursement. Further definition as “chronic systolic” and/or “diastolic” congestive heart failure equates to a standard complication or co-morbidity, thereby increasing the reimbursement. A complete descriptor of acute-on-chronic systolic and/or diastolic congestive heart failure equates to a major complication or co-morbidity, further increasing the hospital reimbursement.
Clear, detailed documentation supports more than optimal reimbursement. The medical accuracy of the patient record is crucial to successful care. Additionally, hospitals use these codes to capture and report statistical data regarding the patients that they treat.
2. Do Avoid EHR Shortcuts
Electronic medical records have simplified documentation and record tracking. In some cases, the electronic record allows the physician to bring forward, or to “cut-and paste,” previous patient information. Although physicians may view this feature as a wonderful time saver, progress notes are critical to supporting successfully the reasons for continued hospitalization. Documentation short cuts can create difficulty in supporting medical necessity for the patient’s continued inpatient status.
For example, if the patient’s improvement and/or regression is not documented in a dedicated note each day, the payer rightly may question whether services are medically necessary. If the notes do not indicate clearly the reason(s) for the patient’s continued inpatient status, the payer may deny some of the days as medically unnecessary.
3. Do Document E/M Elements in Full
Evaluation and Management services often are unsupported at the level billed. New patient visits, consultations, emergency services, observation services, and initial inpatient encounters require that the provider meet or exceed each of the history, examination, and medical decision-making components for the chosen service level. Often, the review of systems section (ROS) is too weak to support the code level that the provider desires to report.
For example, to report a level-IV or -V service, documentation must substantiate the review of 10 body systems. Or, the provider may discuss all positive findings and pertinent negative findings, finally stating that all other systems are negative. If 2-9 systems are reviewed during an outpatient consultation, service cannot exceed 99243 Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family.
The revenue difference between 99243 and 99244 Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family is approximately $60, based upon the current Medicare Physician Fee Schedule. The difference between 99243 and 99245 is approximately $100. Medical necessity should always drive the level of service, but consistently under-documenting just the ROS can reduce revenue substantially.
4. Do Be Exact When Time’s a Factor
Time-based codes, such as critical care (99291-99292), require that the physician document time precisely. Documented time may include face-to-face time, as well as floor time in the hospital. Floor time may include discussions with family, reviewing diagnostic tests, and discussions with other providers involved in the patient’s care. The time does not need to be continuous, but any time spent with other patients, or away from the unit on which the patient is admitted, must be deducted from the total time reported.
5. Do Give Procedure Specifics
Surgical notes should identify clearly the approach, all procedures done at the surgical encounter, and unusual situations that occurred during the operative session. For instance, multiple spinal injections require that the provider identify whether the injections are bilateral in the same level or in several levels. Or, if a procedure is stated as “complicated,” the provider should be precise as to how the determination was made.
For example, lesion measurements should be stated, and specify whether the measurement includes the margins and when the measurement was taken. If the coder must rely on the pathology report for the size of lesion, the measurement will not be as accurate as it would be if taken before the tissue was removed from the blood supply. For instance, documentation specifies that a 3 cm, benign lesion was excised from the patient’s face. This would be reported as 11443 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm. Because the documentation did not mention a margin of .4 cm on all sides, however, the opportunity to report 11444 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 3.1 to 4.0 cm—which pays approximately $50 more than11443—was missed.
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Documentation