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November 2013

Inside the Documentation Pressure Cooker
By Elizabeth S. Roop
For The Record
Vol. 25 No. 15 P. 10

Coders and CDI specialists sometimes feel the heat to chart in a questionable fashion.

From nonpayment for reasonably preventable hospital-acquired conditions (HACs) and higher reimbursements for core measures compliance to publicly available quality comparisons, the pressure is on health care providers to step up their game with regard to care outcomes. The dark side of this push for perfection is the pressure it can place on coders and clinical documentation improvement (CDI) specialists to query less (or more) to support financial or quality objectives.

“The challenge to stay informed as a coder and/or a CDI reviewer is growing exponentially because portions of quality measures can be based on coding, such as value-based purchasing, HACs, and mortality outcomes,” says Paul Evans, RHIA, CCS, CCS-P, CCDS, regional clinical documentation manager for Sutter West Bay in California.

Subtle Pressure
Though not widespread, some evidence suggests that coders and CDI specialists are being pressured to misrepresent a patient’s medical condition or treatment to increase reimbursement, justify medical necessity, improve publicly reported data, or qualify for insurance coverage. In some cases, it’s subtle pressure to not ask questions.

Jon Elion, MD, FACC, founder and CEO of ChartWise Medical Systems and a frequent speaker on ethical documentation practices, cites the example of a physician who wondered whether he should document every case of altered mental state as encephalopathy. Coders and CDI specialists were hesitant to query after a documentation improvement consultant brought in by the hospital encouraged against doing so because documenting a major complication or comorbidity (MCC) of encephalopathy would result in increased revenues.

“It’s a judgment call on the part of the physician. Query guidelines say if there are multiple choices, the query must include all things that are clinically relevant, not just the ones that pay well,” says Elion, adding that “some companies will even train you to find one MCC and move on because, once you have one, you can’t get the reimbursement any better, so don’t waste your time. It’s all about pursuing reimbursements.”

Elion shares two other examples of reimbursement-driven overcoding incidents in which coders and CDI specialists played an unwitting role. One involved a hospital that reported a whopping 38% of its hypertension cases as malignant hypertension, netting approximately $3,000 more per case. Other hospitals in the same state reported a 2.6% incidence of malignant hypertension cases during the same time frame.

The second example occurred at a facility that reported 1,030 cases of kwashiorkor in its Medicare patients, resulting in reimbursement of $11,463 per patient. However, some patient charts had no indication of edema or swelling, and no nutritional consult was ordered. Meanwhile, the next highest incidence in the state was 172 patients.

“Unfortunately, a few hospitals are giving everyone a bad name. We see them in the newspaper,” Elion says. “A hospital in California had a 20% incidence of sepsis. You can’t have that. It turns out that they were just twisting the definition [of sepsis]. Clinically, it wasn’t, but numerically, it was.”

Another example is a patient who develops abdominal tenderness and a fever following gallbladder surgery. A CT scan is ordered along with a course of antibiotics. The patient improves, but the resulting clinical documentation doesn’t indicate a possible infection (“probable peritonitis”). “If you document infection, you’re showing a complication,” Elion says. “Don’t game the system. Don’t try to figure out the right answer. Just document very thoroughly, and don’t be afraid of the complications.”

He adds that these situations are why “compliance officers are scared. They have to achieve a balance. You are supposed to get reimbursed. You are supposed to get paid for what you do, so you have to document as thoroughly as possible.”

Other examples include pressure to stop querying for HACs that are not present on admission or for diagnoses that will adversely affect core measures performance. In other cases, CDI specialists have been asked to stop querying for postoperative complications or not to pursue the diagnosis of acute blood-loss anemia because it may reflect poorly on current or future quality metrics.

“It is important for physicians to understand that CDI and coding professionals have a legal duty to abide by industry and governmental conventions and rules,” Evans says. “In my opinion, a vital function of coding is to ensure the clinical picture of each and every encounter is reported accurately, and this is based strictly and explicitly upon provider documentation. We are also compelled to operate in a compliant manner in keeping with the various standards of ethical coding, and these state, among other things, that we will strive to accurately report conditions that are documented. These standards also state that we will follow the published coding guidelines and conventions in order to accurately report [code] the clinical picture of each encounter. In other words, we will not act to misrepresent any encounter.

“Some providers may not understand that CDI and coding staff operate in a regulated environment governed by strict rules of conduct,” he continues. “Further, some of these rules and conventions of coding and billing are obscure, and some of these coding rules may not be congruent with the provider’s understanding of various clinical situations. In other words, it can seem at times that clinicians and coders do not speak the same language.”

But it’s not just physicians applying the pressure. In perhaps the most highly publicized case of altering documentation to generate higher revenues, the physicians themselves were on the receiving end of the pressure.

In 2009, Johns Hopkins Bayview Medical Center in Baltimore agreed to pay $2.75 million after it was discovered that employees were reviewing charts to determine whether there was any way for the hospital to boost reimbursement by increasing the severity of the secondary diagnoses recorded for certain patients. They allegedly focused on lab results that may have indicated the presence of a complicating secondary diagnosis and advised treating physicians to include such a diagnosis in the medical record, even if the condition was not actually diagnosed or treated during the hospital stay.

Unintended Consequences
Most of the anecdotes about pressuring coders and CDI specialists to back off queries appear to be an effort to avoid the appearance of poor quality, whether through a drop in core measures performance or surgical complications. However, the tactic can have several unintended consequences, including failing to paint an accurate picture of case complexity. “There is definitely a dilemma for surgeons,” Elion says. “You want to show a low complication rate if you’re a surgeon because if there are a lot of complications, you might not be considered good. But the flip side is that you want to show risk-adjusted mortality. You really want to find comorbidity and not complications. The biggest one would be anemia. Was it a complication or not?”

Providers must understand that significant and reportable comorbid conditions, including chronic conditions, should be documented and coded so that outcomes data will be risk adjusted, Evans says. Failure to do so actually can put providers at greater risk of poor outcomes data when they are measured against those with properly reported risk factors.

“However, taking into account the positive impact coding may have upon such quality profiles and outcomes measures, one should not solely review ‘coding’ or code sets in order to judge clinical outcomes,” Evans notes. “Only a qualified physician peer can truly perform a peer review for quality purposes. Coding is one part of the quality picture because coding can help provide risk-adjusted outcomes data by reporting complexity and the acuity of care rendered.”

For example, raw, unadjusted data on coronary artery bypass graft outcomes may show that the percentage of patients who died within a specified period of time was 5% at one facility and 3% at another. But this may not be a true reflection of care rendered or a valid comparison of outcomes. One site may have a higher expected rate of mortality because it accepts patients with higher known risks of poor outcomes. Detailed documentation and coding theoretically will refine outcome data to adjust for these higher risks of mortality. However, these risk-adjusted models are only as valid as the codes used to report each encounter.

“When you treat the very sick patients, observed ratios of mortality may be higher at one site vs. other sites that perhaps transfer these patients to a tertiary care center; you have to look at the risk-adjusted data,” Evans says. “That is my job, to help ensure the documentation allows for coding that accurately represents the complexity of each case. My purpose is not to game the system. My purpose is to make sure that what we present via our data is accurate.”

Elion recalls meeting with a group of hospital representatives who were embarrassed about their facility’s high mortality rate from simple pneumonia. After looking into several cases, it was determined the hospital was not documenting thoroughly. As it turned out, proper documentation would have led to diagnoses of complex pneumonia, which carries a higher expected mortality rate. “You can’t hide death,” Elion says. High mortality rates “are a motivation to document everything.”

Perhaps the most serious unintended consequence of succumbing to the pressure to misrepresent a patient’s condition or treatment is the impact it can have on safety. When the patient record is not thorough and accurate, it can negatively affect future treatment decisions. For example, if a physician documents chronic kidney disease but does not indicate the stage, the next medical team doesn’t know the full extent of the patient’s kidney function. That could hamper treatment decisions as well as performance measures.

“It’s easier to infer and present data in a way that supports quality of care if documentation is good,” Evans says. “It leads to precise coding, which can lead to more accurate predictive models that take into account factors that are risk adjusted. So if I’m working at a hospital where documentation isn’t that precise, my observed mortality ratio after grafting may not accurately reflect care.”

Kim Carr, RHIT, CCS, CDIP, CCDS, clinical documentation manager for HRS, a clinical coding and HIM consulting firm, notes that accurate and complete information will reveal that the appropriate quality of care was delivered. It also can aid in identifying ways to improve care through better collaboration across provider organizations. An example is a patient with a Foley-associated urinary tract infection (UTI) that was not hospital acquired and was coded properly on admission. Should that patient return with another Foley-associated UTI, proper initial documentation will allow the physician to see that it’s a recurrent problem and that there may be something taking place at home that should be addressed through caregiver education.

“It goes both ways to the quality of care,” Carr says. “If you’re able to pinpoint if it’s Foley associated due to outside [factors] and you can provide education, quality of care will improve. It all comes down to accurate documentation. … You have to have the documentation to support whether it’s hospital acquired or outside the hospital. You must continue to be aggressive and go after the most complete documentation you can to support that.”

Education and Guidelines
Most agree that education can help deflect and eliminate the pressure to code certain elements of care. Carr says the ICD-9-CM Official Guidelines for Coding and Reporting calls for coders and providers to work jointly to achieve the most accurate record possible. “It’s all about physician education,” she says. “That falls on CDI specialists and coders. Physicians don’t think in terms of complications when they document the term ‘post-op.’ To them, it’s just a period when a condition happened. The term ‘post-op,’ when referenced in the ICD-9-CM codebook, will index to a complication. We, as CDI specialists and coders, need to educate our physicians and ask the question, ‘You say post-op, but is it a complication or just the time period when the condition happened?’ If you don’t ask the question, some conditions will default to a complication.”

New Hanover Regional Medical Center in Wilmington, North Carolina, has established clear guidelines that outline the process for querying to clarify HACs, complications, and any unclear documentation regardless of its impact on quality metrics, according to Linda Rhodes, RN, BSN, CCDS, the hospital’s CDI manager. For example, if a clinical documentation specialist notices documentation that is inconsistent with the clinical picture, the case is referred to the manager/physician advisor. A possible query is posed or a discussion takes place with the provider to clarify the documentation.

“As part of our clinical documentation presentations, we include education on the necessity of clinical indicators for diagnoses,” Rhodes says. “Documentation that is clear, consistent, concise, and accurate paints the clinical picture for all health care providers that come into contact with the patient. The documentation communicates the medical decision-making and complex thinking skills of the provider and describes treatment plans. However, I have reviewed charts where the documentation is lacking, but I know firsthand that the quality of care provided at the bedside was excellent. It is then incumbent upon the clinical documentation specialist to get the needed documentation into the record.”

Rhodes adds that coders or CDI specialists who find themselves being pressured to alter documentation are instructed to notify their manager, the compliance department, or even the chief medical officer. “We have never subscribed to the philosophy of coding for highest reimbursement per se,” she says. “Our philosophy has always been that documentation/codes should accurately depict the condition of the patient. The reimbursement will follow. … We [also] use that data to identify areas needing improvement with core measures, sepsis outcomes, etc and to monitor improvements in outcomes.”

Evans, who also encourages coders and CDI specialists to contact their internal compliance department if they feel they are being pressured to under- or overcode for the sake of metrics, says one way to build common ground may be to reference generally accepted evidence-based criteria to define, document, and code key conditions. Ideally, there is a physician champion who can help build such query forms and act as a liaison between coders, CDI specialists, and physicians.

“Using acceptable and valid criteria for diseases developed and endorsed by physicians helps ground the process, enhancing credibility,” Evans says. “That’s where knowledge of and employment of key criteria can help a coder or a CDI professional. However, on the down side, it should be recognized by management that employment of such criteria will surely affect a coder’s productivity given the extra time it will take the coder to examine the record in such a critical manner.”

One specific example of using criteria is postoperative ileus. Currently, when this term is charted, it may be coded as a complication based on indexing found in official coding references. This can be a problem because some charting takes place soon after certain procedures when slow return of bowel function is expected and integral. Evans notes this can lead to false reporting of ileus with subsequent improper payments as well as skewed outcomes for certain providers.

A possible solution is to incorporate query language revolving around ileus that surgeons find clinically valid and acceptable. For instance, build a query built on the National Surgical Quality Improvement Program definitions, as follow:

• Prolonged postoperative ileus: patient with an ileus managed with a nasogastric tube and/or the patient is NPO for ≥ postoperative day 3.

• Postoperative ileus: Although ileus has numerous causes, the postoperative state is the most common setting for the development of ileus. Indeed, ileus is an expected consequence of abdominal surgery. Physiologic ileus spontaneously resolves within two to three days after sigmoid motility returns to normal. Ileus that persists for more than three days following surgery is termed postoperative adynamic ileus or paralytic ileus.

Both AHIMA (Ethical Standards for Clinical Documentation Improvement Professionals) and the Association of Clinical Documentation Improvement Specialists (Code of Ethics) have published guidelines for ethical documentation.

Ultimately, however, it comes down to the organization’s culture. “If it’s an environment that is not forthright, and people are trying to twist the rules to get the best reimbursement, that permeates through an organization,” Elion says. “But when the entire organization is set on an ethical path, you can be ethical with yourself [and] you can be honest with yourself and with your own reports. … They are sleeping well at night, and their compliance officers are happy. It may sound corny, but if you pursue a high-quality medical record, the proper reimbursement will follow.”

— Elizabeth S. Roop is a Tampa, Florida-based freelance writer specializing in health care and HIT.


Questioning the Clinician
The pressure that coders and clinical documentation improvement specialists are feeling doesn’t just come from providers. According to Paul Evans, RHIA, CCS, CCS-P, CCDS, regional clinical documentation manager for Sutter West Bay, what’s even more disturbing is the expectation that every diagnosis will be questioned, even when the documentation is unambiguous.

For example, the July 2011 issue of Medicare Quarterly Provider Compliance Newsletter: Guidance to Address Billing Errors highlighted a case in which, upon auditor and physician review, it was determined that the clinical evidence did not support a diagnosis of respiratory failure “despite physician documentation of the condition.” The principal diagnosis subsequently was changed and, as a result, the auditor determined an overpayment had been made.

Recovery audit contractors (RACs) essentially are “saying a diagnosis code should have been questioned because the coder should have known the physician was wrong,” Evans says.

However, the Centers for Medicare & Medicaid Services, via its RAC guidelines, isn’t the only organization pushing coders to question diagnoses. Evans notes that AHIMA, in its own “Guidelines for Achieving a Compliant Query Practice,” published last February, calls for coders to query when clinical indicators are lacking from the record: “When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, it is currently advised that a query be generated to address the conflict or that the conflict be addressed through the facility’s escalation policy.”

“Not everything is proven by a lab [result]. That doesn’t mean I go back and question the physician,” Evans says. “The problem with that is it places the coder, in the culture of the hospital, in a very tenuous position. If sepsis is written multiple times in the chart and I go back to a senior physician [to question it], who is going to support me? It’s very controversial to put that at the feet of the coder, yet that’s what we are being told to do.”