One of the problems Kathy DeVault, RHIA, CCS, CCS-P, manager of professional practice resources for the American Health Information Management Association (AHIMA), sees is a lack of continuity between initial admitting diagnosis and discharge summaries. For example, a hospitalist might admit a patient for acute renal failure—the correct diagnosis—and be able to reverse the condition fairly quickly, especially if the failure is due to dehydration.
The patient, whose issue is resolved, could be discharged by an attending physician who does not note the acute diagnosis in the summary. “That acute condition disappears, and the RAC auditor may then challenge the claim for payment,” DeVault says.
The Remedies
Leon-Chisen
Table 1. How Key Principal Diagnoses Affect Hospital Reimbursement
While physicians might think that they don’t have the time to acquire coding education, there could be other incentives coming down the pike. Dr. Pinson has noticed that hospitals are beginning to incorporate documentation accuracy into their contractual reimbursement formulas.
Documentation fixes vary according to domain. A hospital’s clinical documentation specialists can query physicians for clarity and detail in their notes; for instance, a diagnosis of congestive heart failure (CHF) must be accompanied by additional documentation stating whether the CHF is acute or chronic, and whether it is systolic or diastolic.
Many hospitals have instituted clinical documentation improvement (CDI) programs, sometimes called clinical documentation integrity programs, to address documentation discrepancies. CDI programs are essential to hospitals’ financial survival, Dr. Pinson says, and hospitalists are ideally positioned to join those efforts.
“[The hospitalists] are the most important people to the hospital in all of this,” he says. “They’re at the center of this whirlpool. If you have these skills, your value to the hospital and to your group is greatly enhanced.” (Visit the-hospitalist.org to listen to Dr. Pinson discuss HM’s role in documentation improvement.)
Leon-Chisen also says that the relationship between coders and physicians should be collaborative. “If it’s adversarial, nobody wins,” she points out, adding that CDI programs present an opportunity for mutual education.
Conducting audits of the practice’s documentation and coding can identify coding strengths and weaknesses, says Pierce, who is faculty for SHM’s billing and coding pre-course and regularly consults with hospitalist groups. Audits are helpful, she says, not just for increasing group revenue, but for compliance reasons as well. “You need to know what you’re doing well, and what you’re not doing quite so well, and get it fixed internally before an entity like Medicare discovers it,” she says.
It’s no doubt difficult for a busy HM group to stay on top of annual coding updates and changes to guidelines for reporting their services, Leong notes. Her company has worked with many hospitalist groups over the years, offering coding workshops, “back end” audits, and real-time feedback of E/M and CPT coding choices. If all of the hospitalists in a group cannot convene simultaneously, Leong provides the feedback (in the form of a scorecard) to the group’s physician champion, who becomes the lead contact to help those physicians who struggle more with their coding. (Leong talks more about real-time feedback and capturing CPT and E/M codes at the-hospitalist.org.)
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In lieu of hiring professional coders, some HM groups use electronic coding devices. The software could be a standalone product, or it could interface with other products, such as electronic medical records (EMRs). These programs assist with a variety of coding-related activities, such as CPT or ICD-9 lookups, or calculation of E/M key components with assignment of an appropriate level of billing. Leong, however, cautions too much reliance on technology.