Accurate coding has a significant impact not only on a hospital or practice's finances but also on quality ratings, as Medicare's new coding system increasingly is being used to profile hospitals and physicians, according to a session on improving clinical documentation at Hospital Medicine 2009.
After giving a brief review of the 2008 change from CMS Diagnosis-Related Groups (DRGs) to Medicare Severity-Based DRGs (MS-DRGs), presenter Bryce Gartland, MD, of Emory University, warned of the financial penalties for imprecise documentation. Under the new system, diagnoses are now classified as being with or without complications/comorbidities (CCs) or major complications/comorbidities (MCCs)—and choosing the wrong option can be costly. For example, the reimbursement for heart failure and shock with MCC is $8,218 versus $3,959 for heart failure without CC or MCC.
“Documentation has astonishing financial impact for hospitals,” Dr. Gartland said, and physicians have done a historically poor job at it. Dr. Gartland cited a 2007 review showing that doctors used nonspecific codes for 97% of congestive heart failure cases, 62% of chronic obstructive pulmonary disease cases, 81% of diabetes cases, and 82% of hypertension cases.
To optimize documentation, Dr. Gartland offered the following tips
- 1. Be specific. “If you're not specific, it usually doesn't correspond with a specific code with an ICD-9.”
- 2. Emphasize acute diseases and chronic diseases with acute exacerbations, those that are end-stage or those with extensive disability. “For those who like acronyms, we've come up with ACE3,” he said.
- 3. Remember that “In coding world, the words ‘possible,’ ‘probable,’ ‘likely,’ and ‘suspected’ all count.”
- 4. Don't forget the small stuff, such as electrolytes and nutrition status.
Dr. Gartland also offered advice on coding for certain diseases and conditions. For example, for gastroenterological disease, hospitalists should be specific about biopsy and ulcer sites and should also ask the following questions
- Is there any acute or chronic blood loss for those being admitted with melena or hematemesis?
- Is the gastroenteritis viral or infectious?
- Is there any associated dehydration?
- Are there any signs or symptoms of gastrointestinal obstruction or ileus?
For neurological disease, hospitalists should document the duration of transient ischemic attack symptoms, specify whether the patient has a seizure disorder or epilepsy, and document whether a cerebrovascular accident is an infarct and, if so, its specific location, Dr. Gartland said. For diabetes, note whether it's type 1 or type 2, whether it's controlled or uncontrolled, and whether it has any associated conditions, such as diabetic neuropathy, he said.
He also cautioned hospitalists about using shorthand, such as up or down arrows, when documenting electrolytes or other laboratory values.
“The up or down arrow is not codable,” he said. “You have to write out what the diagnosis is.”
Relating coding to quality
Although Medicare's DRG system was never intended to act as a measure of quality, Dr. Gartland said, the financial data it generates are being used that way.
“It's important for us to recognize that these DRGs are being used to profile hospitals as well as physicians,” he said.
Accurate coding is linked to quality, Dr. Gartland said, because failing to accurately document comorbidities or complications makes the risk for death look lower than expected.
“As physicians, we tend to underestimate the severity of illness by 8% to 15% and the risk for mortality by 15% to 30%. When that expected mortality looks lower, in turn, that mortality index looks significantly higher,” he said. Accurate and complete documentation, on the other hand, helps align expected and accurate mortality, improving the overall picture of quality of care.
Dr. Gartland also addressed Medicare's recent focus on value-based purchasing. “This is fundamentally changing our health care system because it's transforming Medicare from a passive payer of claims to an active purchaser of care,” he said.
Because Medicare no longer pays for care of certain conditions that develop in the hospital, physicians need to clearly document whether a condition was present at hospital admission. Hospitalists should document the time, not just the date, of admission and should also remember that anything happening in the emergency department is considered preadmission, Dr. Gartland noted.
“If a patient's down in the emergency room and somebody's putting in a central line and [the patient] happens to have a pneumothorax from that, that pneumothorax was actually present on admission because the patient was not admitted to the hospital,” he said.
Perhaps most important, hospitalists should keep in mind that clinical language does not equal coding language, Dr. Gartland said.
“It didn't happen if it's not documented properly. It doesn't exist if not documented properly,” he said. “We have to retrain our brains to understand that we actually have to document not only to convey knowledge from one care team member to another but also to make sure that [the] coding [department] understands specifically what we're doing.”