Improved documentation: leveraging staff training, benchmarking, technology, and process change for accurate payment

Healthcare Financial Management, April, 2008

Since the program began, Sentara has reduced the gap between its experience and national benchmarks, increased its cases that are in higher-weighted DRGs, and realized a net benefit of $1.5 million in additional payment.

* Physician Involvement

While there is no right or wrong way to structure a concurrent documentation program, what's common to all of them is the need to get physicians on board. What physicians write in the medical records of their patients directly impacts the hospital's public profiling scores and payment. If physicians don't provide information in language that can be coded, a medical condition will go unreported, and the downstream effect will be missed payment and skewed mortality, complication rates, and other quality metrics.

Typically, physicians have not been taught to be specific in their documentation. They commonly use shorthand devices--symbols such as up and down arrows or abbreviations-or they refer to lab work or radiology reports, which may be appropriate from a clinical standpoint but can't be used by coders. For example, while a down arrow written before "blood pressure 70150" may mean shock to a physician, coders are required to follow rigid Medicare coding rules and will need a specific diagnosis of "hypotension" or "cardiogenic" or "hypovolemic shock."

And things just got a lot more complicated with the release of the new severity-based MS-DRG Medicare coding system. Diagnoses that once were taken for granted as a CC that would routinely place a case in a higher-weighted DRG are no longer considered clear routes for payment increase. DRGs that were more heavily weighted simply because of the presence of complications and comorbidities now must be categorized by whether the CCs are major or minor.

A classic example is congestive heart failure, which last year was labeled a CC that would affect DRG assignment. This year, a straightforward diagnosis of congestive heart failure will not be regarded as a CC unless a physician reports it is acute systolic or acute diastolic heart failure. Massive re-education is needed to make physicians aware of the greater specificity that's needed for documentation.

Physicians need to understand that documentation is not just a hospital reimbursement problem. Physicians need to realize they are partners with the hospital and that what's good for the hospital in the end is also good for the physician.

"There is an urgency for all of us to understand the need to partner for accurate documentation," says Burton of Sun Health Boswell Hospital.

The good news? Physicians are becoming more receptive as they learn about initiatives such as pay for performance, says Barbara Minick, vice president of professional services for Sun

Health Boswell Hospital.

"As pay for performance gets talked about in a variety of settings--not just for hospitals but also for physicians--the awareness of the need to collaborate and partner with hospitals is definitely heightened, although you still have the challenge of getting physicians to understand what they can do to help the hospital, which is not necessarily their first priority," she says.