Why Documentation Does Matter

Why Medical Record Documentation Truly Matters

The OIG just released another one of its’s many Medicare Compliance Reviews on hospitals throughout the country. This review involved Mount Sinai Hospital for the time period 2012-2013. The hospital is a 1,171-bed acute care teaching hospital located in New York City. According to CMS’s National Claims History data, Medicare paid the Hospital approximately $842.4 million for 36,262 inpatient and 361,784 outpatient claims for services provided to beneficiaries during CYs 2012 and 2013 (audit period). The OIG audit covered $74,679,543 in Medicare payments to the Hospital for 6,369 claims that were potentially at risk for billing errors. They selected for review a stratified random sample of 261 claims (144 inpatient and 117 outpatient) with payments totaling $4,375,619. These 261 claims had dates of service in our audit period. https://oig.hhs.gov/oas/reports/region2/21401019.pdf

What the Audit Found

As in most OIG Medicare Compliance Reviews with a strong focus upon commonly identified high risk areas from previously conducted hospital compliance reviews, the OIG in this OIG Mount Sinai review found the Hospital was in supposed noncompliance with Medicare billing requirement leading to alleged overpayment. In this instance, the OIG is stating based upon review of 261 claims (144 inpatient and 117 outpatient) in the audit period that the hospital did comply with billing regulations on 110 claims, resulting in overpayment of $1,374,339 for the audit period. Specifically, 78 inpatient claims had billing errors, resulting in overpayments of $1,200,390 and 32 outpatient claims had billing errors, resulting in overpayments of $173,949. 

Some Comments

Two categories of billing errors associated with inpatient claims is worth of note and discussion. Incorrectly billed as inpatient accounted for 36 of the 78 inpatient claims billed in error while 6 inpatient claims were billed with incorrectly assigned DRG. For the latter, the hospital agreed that 3 inpatient claims were billed incorrectly with inaccurate DRG assignment attributable to: 1) documentation insufficiencies not initially identified by the Hospital’s DRG Validators and 2) one claim was coded incorrectly due to a typographical error. Of note is the 36 inpatient claims billed in error were in two risk areas (1) elective procedures (26 claims) and (2) high severity level DRG codes (10 claims). The Hospital did not provide a cause for the remaining three errors because it did not agree with the findings. As a result of these errors, the Hospital received overpayments of $74,531.

Incorrectly billed as inpatients equates to level of care decisions, whether the patient “met screening criteria” considering patient’s severity of illness, risk of morbidity and mortality (risk of an adverse event), past medical history, comorbid condition and nature of presenting problem. Commercial third party payers utilize screening criteria for determining appropriateness of level of care while Medicare now employs the 2 Mid-Night Rule in guiding and determining appropriateness of inpatient admission versus observation. The 2 Mid-Night rule was not in existence during the time-period of this audit. Regardless of patient level of care chosen by the physician as exemplified in his/her order, clear, concise and consistent documentation is essential to support, substantiate and justify the appropriateness of the level of care. Appropriateness of level of care is predicated on clinical documentation that clearly outlines the clinical information and facts of the case, providing for a sharp picture of the patient’s presentation to the Emergency Room or hospital for direct admission, what was the patient’s chief complaint, what was the patient’s History of Present Illness, what were the findings of the physical exam, risks associated with and posed by the patient’s Past Family Social History, results and clinical significance of diagnostic workup results, what was the physician’s clinical thoughts in the assessment including clinical rationale, did the assessment include provisional diagnoses that are reasonable in light of physician presentation, and was there a plan of care congruent with the assessment. These serve as a reasonable basis for determining the appropriateness of inpatient level of care assignment.

What is known clinically at the time of admission is used to determine the appropriateness of admission; whatever develops after admission can only be used to further support versus refute the decision to admit the patient as an inpatient. The key point here is “what is clinically known at the time of admission” and “clearly documented” in the record is critical in nature to support any inpatient admission. The attending physician must create documentation that communicates to healthcare stakeholders including Medicare and other third party payers a clear clinical picture of the patient encounter as outlined in the History and Physical. Simply put, while Cliff Notes may be beneficial and helpful in high school with Shakespeare homework assignments, they will not suffice when it comes to documentation of patient care in the medical record!

Enter the Clinical Documentation Improvement Specialist

The Hospital outlined in its comments in the report the rationale for their disagreement on the merits of OIG’s determination on the improper billing of inpatient claims. After review and consideration by the OIG, they still stood by their contention 36 of the inpatient claims were billed inappropriately. In its arguments, the Hospital outlined its adherence to official Medicare guidelines governing observation versus inpatient admission consisting of the benchmark of 24 hours, specifically Chapter 1 of the Medicare Benefit Policy Manual as indicated below. Of note is the Hospital’s contention the physician’s clinical judgment to admit these patients for the more intense level of inpatient care fully complied with the Medicare guidelines for coverage of inpatient services.

·       An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as inpatient with the expectation that he or she will remain at least overnight and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight. ...

·       Physicians should use a 24-hour period as a benchmark, i .e., they should order admission for patients who are expected to need hospital care for 24 hours or more, and treat other patients on an outpatient basis. However, the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors ...

·       Admission of patients are not covered or non -covered solely on the basis of the length of time the patient actually spends in the hospital.

The question that remains is whether the physician explicitly executed documentation of his/her clinical judgment in the record to the extent an outside reviewer can quickly, easily and reliably draw a reasonable conclusion that patient’s severity of illness, risk of adverse events and other relevant factors supported and substantiated an inpatient admission. During the audit time- period, 24 hours was the benchmark and under today’s Two Mid-Night rule the benchmark is at least two Mid-Nights of hospitalization. My extensive experience reviewing medical necessity denials as well as clinical validation denials demonstrates that most medical necessity denials are self -inflicted, avoidable and unnecessary. They can be avoided with “sufficient” documentation of physician clinical judgment in the H & P and within progress notes. Sufficient documentation does not equate to more documentation, just more effective documentation. Clinical judgment can be defined as a physician’s assessment of a patient’s clinical scenario and the initiation of action congruent with the assessment.

How can CDI specialists assist in the accurate reporting and reflection of clinical judgment, so integral and vital to establishment of medical necessity? First, CDI can start by transforming the framework in which we currently operate, moving away from the outdated transactional reactional repetitive knee jerk approach to CDI. Instead, we should embrace a proactive approach reviewing the record at the time of admission given most facilities utilize the electronic health record where documentation is available in almost real time. Given only what is known at the time of admission can be used to judge the reasonableness of a decision to admit the patient as an inpatient, it makes logical perfect sense to focus upon coaching the physician on recording of the work performed in assessing the patient’s clinical scenario and developing an assessment and congruent plan of care.

A couple of more points to make- where CDI really needs to initiate immediate action is focusing upon high weighted DRGs, observation cases that convert to inpatient status and inpatient cases that originated initially from outpatient elective surgeries. Why? Often times the documentation is devoid of physician clinical rationale and thought processes complemented by a vivid picture describing and showing an accurate depiction of the “snapshot” picture of the patient’s clinical situation at the decision to admit the patient as an inpatient. The review of these charts should be assimilated into the regular CDI review process with an open mind and eye for detail beyond searching for a CC/MCC or optimization of a principal diagnosis. Our goal should be promoting, achieving and making a compelling argument for a record that speaks for itself through an ability to recognize documentation insufficiencies and engage in a candid conversation on the merits of capturing the clinical picture and clinical judgment of the physician in a concise fashion in the record. What is needed is not a book, thesis or cut and paste information. Just a brief note will suffice. The other point is consistency in documentation is paramount to communication of patient care. CDI potentially contributes to unnecessary denials through the grab and run mentality of querying of a physician, securing a win with a documented diagnosis and then running to the next chart. This practice must cease as evidenced in the OIG citing instances, although small, of inconsistencies in documentation leading to incorrect DRG assignment. It is not incumbent of DRG validators to identify these instances; instead the duty is on CDI to avoid these situations by securing consistent documentation of a diagnosis or diagnoses throughout the record.

 Closing Note

In my next article, I will proceed to outline how the CDI can review the H & P, identify insufficiencies in documentation of the physician’s assessment, and strategies to best address and work with physicians to truly improve the quality and effectiveness of their communication of patient care. Ultimately, all healthcare stakeholders including the patient as well as the integrity of the revenue cycle are benefactors of solid documentation. Stay tuned.