Documentation Improvement | Compliance Audits | ICD-10 Education & Coding

When More Than Just Diagnoses Matter
As stated in the AHIMA Clinical Documentation Improvement Toolkit released in May 2010, goals of a Clinical Documentation Improvement Program include the following:

This same toolkit goes on to state that the “purpose of a CDI Program is to initiate concurrent, and as appropriate, retrospective reviews of inpatient health records for conflicting, incomplete, or nonspecific provider documentation. The goal of these reviews is to identify clinical indicators to ensure that the diagnoses and procedures are supported by ICD-9-CM codes.”

Clinical Documentation Improvement Program Focus

In general, the focus of most clinical documentation improvement programs is upon clarifying inconsistencies in clinical documentation, clarifying additional clinical conditions actively being managed, and obtaining specificity in clinical documentation through the written and verbal physician query process.  The crux of the process is clinical queries leading to enhanced clinical documentation, thereby facilitating improvement in clinical coding accuracy and MS-DRG assignment. MS-DRG assignment in this instance customarily leads to improved reimbursement, a concept CMS has recognized and reacted by instituting a Documentation and Coding Adjustment of 2.9% for FY 2011 and FY 2012. However, there is one critical missing piece that needs to be considered when judging the effectiveness and practicality of any clinical documentation improvement program, a piece that has not been given much thought or consideration.

OIG Report Highlights the Missing Piece

The CMS established the Comprehensive Error Rate Testing Program (CERT) to produce a Medicare fee-for-service error rate. An error, or improper payment, is the difference between the amount Medicare paid to a health care provider and the amount that it should have been paid. Using the results of the CERT program, CMS annually submits to Congress an estimate of the amount of improper payments for Medicare fee-for-service claims pursuant to the Improper Payments Information Act of 2002. The annual CERT Program Report is issued and available for review in the month of November.

The OIG released in July 2010 a report titled Analysis of Errors Identified in the Fiscal Year 2009 Comprehensive Error Rate Testing Program available through accessing the following link (XXXX). As noted in this report, for FY 2009, the CERT Contractor sampled 99,480 claims valued at about $71 million. The CERT contractor found that 19,754 sampled claims resulted in improper payments valued at about $4.7 million. Based on these sample results, the national paid claim error rate for FY 2009 was 7.8 percent ($24.1 billion). Six types of providers accounted for $4.4 million, or 94 percent, of the $4.7 million in improper payments identified by the CERT contractor. Not surprisingly, inpatient hospitals accounted for 40 percent of the improper payments with a total of $1,912,323.

The most significant types of payment errors attributable to these six types of providers were (1) insufficient documentation, e.g., missing clinical notes or test results and missing, incomplete, or illegible physician orders, which resulted in improper payments totaling $2.6 million; (2) miscoded claims, which resulted in improper payments totaling $0.9 million; and (3) medically unnecessary services and supplies, which resulted in improper payments totaling $0.8 million. These types of payment errors accounted for about 98 percent of the $4.4 million in improper payments associated with the six types of providers. The most significant types of inpatient hospital claims accounted for 40 percent of the $4.7 million in improper payments. These errors can be categorized into medically unnecessary services, insufficient documentation, and miscoded claims.

Medical record inpatient stays were denied on the basis of insufficient documentation if the clinical documentation was not of substance and nature necessary to make an informed decision that the services billed were medically necessary. These improper payment determinations related to missing or incomplete:

 

Clinical Example Highlights Critical Missing Piece  

The following clinical example of insufficient documentation serves to highlight the critical missing piece of most clinical documentation improvement programs.

Analyzing this case on the surface, the medical necessity for inpatient stay was established on the basis of total hip replacement surgery is traditionally considered an inpatient procedure, given the nature of the surgery and the need for recovery and initial physical therapy prior to discharge.  What is not established in and of itself is the medical necessity for performing the procedure, leading to a very painful financial recoupment from the facility of $10,433 for the total hip replacement.

The missing piece entails clinical documentation beyond establishment of clinical diagnoses throughout the record. Pertinent clinical information to be incorporated into the clinical documentation from Emergency Room admission through discharge include severity of patient signs and symptom upon admission, provisional diagnoses at the time of admission, physician clinical decision-making and undertaken risk stratification, ancillary care staff interventions carried out, patient response or lack thereof to medical treatment, significance of abnormal laboratory and other diagnostic test results, conservative therapy attempted prior to decision for surgery, all necessary in the clinical confirmation of the physician’s clinical diagnoses that are being clarified by the clinical documentation improvement specialists as part of the clinical documentation improvement program.  This clinical confirmation of clinical diagnoses provided by the physician is essential in light of the trend of third party payer medical directors second guessing attending physician clinical judgment by downplaying and disputing clinical conclusions established by the physician in the form of diagnoses supplied throughout and at the conclusion of the stay.

The Expanded Goal of the Clinical Documentation Improvement Program

An expanded goal of any clinical documentation improvement program is to bring to the forefront a complete and accurate picture of the patient stay from admissions through discharge. This complete and accurate picture establishment, by definition, requires a mindset change on the part of all parties involved in the care of the patient, including that of the physicians and the clinical documentation improvement specialists. If you already have invested in a clinical documentation improvement program that is effective and operating smoothly, one needs to ask the question of whether the clinical documentation in its current format will suffice as relates to medical necessity determinations and allegations of insufficient documentation. While diagnoses clarifications are essential for accurate ICD-9 code and MS-DRG assignment, truly complete and accurate clinical documentation forms the basis for an insurance policy that serves to preserve revenue integrity from prospective and retrospective third party payer denials and potential payment denials and recoupments.