Introduction: The national context for documentation as destiny
Although methods of payment influence physician practice patterns, the payment system has not evolved to support changes in practice to coordinate care for patients with multiple chronic conditions.
Recent proposals recommend bundling physician payment with hospital payment. When payments are bundled, physician documentation affects physician reimbursement in the same manner as it affects hospital reimbursement.
Case Presentation: Bundled Payment for an Episode of Care
Let’s say that a surgeon admits a patient with acute diverticulitis and a stage III decubitus ulcer (the skin breakdown looks like a crater, and the tissue below the skin is damaged). The patient has congestive heart failure, which worsens after surgery for diverticulitis. An internal medicine consultant assists with the medical care of the patient. The patient improves and is discharged ten days after admission.
Optimal scenario (1)
During the admission, both the surgeon and internist refer to the patient’s heart failure in the notes as “acute systolic heart failure,” and acute systolic heart failure is included as the secondary diagnosis by the surgeon. The stage III decubitus ulcer is noted on admission. This patient is coded appropriately as MS-DRG 329: major small and large bowel procedures with a secondary diagnosis and major clinical complication (MCC) of acute systolic heart failure and a diagnosis related group (DRG) weight of 4.5. The bundled payment based on a blended rate of $5,000 for the facility is $22,529.
Suboptimal scenario for documentation as destiny (2)
The surgeon uses less precise terminology, such as “heart failure” and does not document that the decubitus ulcer was present on admission. The coding changes to MS-DRG 331, major small and large bowel procedures without complication, and a DRG weight of 1.84, for which the providers receive $9200, a nearly three-fold reduction. Moreover, the decubitus is recorded as an avoidable hospital-acquired condition for which the providers are not paid, making them look like high-cost, poor-quality care providers.
Implications of documentation as destiny
Given the increasing importance of documentation and its relation to patient access and payment, physicians need to master coding language and physician profiling just as they have mastered the knowledge that is integral to medical or surgical practice. Physicians should visit their medical records departments and request information on their top ten admission diagnoses.
Ways that Tenet Hospital is helping physicians understand that documentation is destiny include:
- Educating formal and informal physician leaders about upcoming coding and documentation issues and their effect on physician profiles and their future income
- Having physicians look at physician profiles, using the information to determine the most common DRG diagnoses, and doing a comparative analysis of physician DRG performance versus national benchmarks
- Publicly celebrating physicians who are complying and encouraging them to speak to colleagues about the benefits of improved documentation, both financially and from the standpoint of their public profiles
Although electronic health records can be used to bring up templates, they do not uniformly contain coding language that optimally captures severity on admission. It remains the physicians’ responsibility to understand the coding language for their most common diagnoses to prevent the loss of deserved revenue.
As always, I welcome your input to improve healthcare collaboration and get it done.
Kenneth H. Cohn
© 2011, all rights reserved
Disclosure: I have not received any compensation for writing this content.