October 18, 2017

A Great Day

You are having a great day. You acted quickly and resuscitated that septic patient, and now she is walking around her room asking when she can go home. You led a great family meeting, bringing comfort and closure to a family dealing with a dying loved one and received their hugs – even from the otherwise grumpy nephew. You diagnosed a patient with an occult form of bronchospastic disease and help him to feel great again after feeling short of breath for months and having multiple admissions to the hospital. He asks if you can be his PCP, and you politely decline, explaining that, professionally, you never leave the halls of the hospital, but you promise to talk to his current PCP so nothing is lost in the transfer. You are awesome. You know it, and so do your colleagues. While opening your email, you receive a report card from the utilization management (UM) committee.  The UM Director informs you that, compared to your colleagues, you have a higher than normal rate of unqualified days and your disease-related mortality also exceeds your colleagues’. Your length of stay is a full day longer than average, despite having a lower acuity. “It must be opposite day,” you think as you close the report and feel the air go out of your celebratory balloon. The Chief Hospitalist, however is not as quick to dismiss the report. She tells you the UM committee put a lot of work into coming up with valid metrics and you should take this information seriously. She was surprised by the results and personally audited a few of your charts. “Fortunately, the clinical care you are providing to patients is superb. Unfortunately, your documentation does not paint the picture of the excellent clinical care you are providing to payers, quality groups or the hospital’s UM committee. You’ve been labeled as an ‘underperforming provider,’ and the hospital is not getting credit for the acuity of the patients you are caring for each day.” Sound familiar? Whether we like it or not, today’s metrics for how the hospital is paid, how we are paid and how we are performing are based largely on the accuracy of our documentation. Medicine has the old adage, “if you didn’t write it, it didn’t happen.” In truth, a more modern adage would be, “if you didn’t write it in the dialect of coders and payers, it might have happened, but it might not have, and it definitely wasn’t awesome.” Here are a few tips:

Case in Point

A patient with heart failure develops severe shortness of breath after eating a box of crackers and drinking four bottles of water. His respiratory effort is so severe he cannot speak. You are debating intubating him, but instead aggressively start treatment, improving his breathing. The patient is still compromised and requires noninvasive ventilator support, but you feel it is safe to walk away from the bedside. You document the following: “The patient presented to us today with sudden onset shortness of breath, likely from fluid overload after eating a box of Saltine crackers and drinking several bottles of Evian spring water. The ICU declined admission as the patient looks like he turned a corner and is stable. We will observe the patient on telemetry and continue with diuresis. He had an echo recently showing an EF of 15%. The patient’s creatinine is 4.1, up from a baseline of 1.8 last august. The patient’s renal issues will make diuresis slow. We will consult nephrology if the patient’s creatinine continues to escalate and they do not have adequate urine output. The patient’s daughter, who is a pharmacist at the CVS on Main Street, tells me her Father still has crackers at home.” 

Timing is everything.

Is it a condition acute or chronic condition, or is it an acute exacerbation of a chronic disease? Distinguishing this is critical for getting credit for the acuity of a patient you are dealing with. Just documenting that a patient has “CHF” is fairly meaningless to coders. Is it a chronic, but stable, condition that you are keeping in mind as you deliver care to the patient, or is it decompensated and requiring direct attention and interventions or monitoring? This patient clearly has acute on chronic systolic heart failure.

“Galileo and the Pope had a little misunderstanding” – Sheldon Cooper

In our documentation, our word choice might overstate, understate or simply misstate the actual scenario. A few words mean different things to a provider than they would to a coder or reviewer.

  • Stable: To a reviewer, the word stable might imply that the patient has no acute needs. Use words, such as improved, instead. If the patient is still acutely ill, document why this is so. Clarify the patient’s shortness of breath. Are there objective findings that will better clarify it? What is it due to? Be specific.
  • Observed: This might imply that you intend to place the patient in observation status to determine if they need admission. Consider substituting with the word monitor instead.

Clinicians tend to understate a patient’s acuity more often than not, which does not allow us to get credit for the work we do.

What makes this patient sick?

Consider and document both acute and chronic illnesses a patient has and how they affect how you think about this patient’s risk of an adverse outcome. Consider and document the interventions that the patient will need. Articulate why they could not be treated in a less acute setting. Consider adding in an expectation of length of stay, particularly for Medicare patients whose status will depend in part on how many midnights they are in house.

Words, words, words

  • MSDRGs, and CCs and MCCs – Oh my! Be familiar with a few of the more common DRGs and how they are classified. Also be aware of common comorbidities and how they are defined. If you don’t document these well, it will appear that you are taking care of healthy patients who are staying longer than they need to and dying at a higher rate than they should be.
  • Short of breath: This term is not helpful, except to describe that the patient is experiencing a subjective symptom. Consider if the patient is having respiratory failure and whether it is acute, chronic, or acute on chronic.
  • Labs are not diagnoses: A coder cannot use a lab value to code for a diagnosis. Documenting “a troponin of 324” does not help relay how sick a patient is. Make sure you qualify labs with the appropriate diagnosis if they are relevant to the patient.
  • Test findings are not diagnoses: Again, a coder cannot use an “EF of 15% to assume a diagnosis of heart failure. Furthermore the heart failure cannot be further characterized by the coder based on the echocardiogram report.

Putting what we learned to practice

Consider the following substitution: “The patient presented with acute respiratory failure due to acute on chronic systolic heart failure in the setting of dietary indiscretion. The patient was so compromised that he was unable to speak, and we considered intubation and transfer to the ICU, but the patient improved with several IV furosemide boluses and noninvasive ventilator support. He can be admitted to the telemetry floor for monitoring of his still tenuous respiratory status and arrhythmia. The patient has acute renal failure with a creatinine of 4.2, likely due to his heart failure.  This may result in a less-than-optimal response to diuresis. He has stage 4 chronic kidney disease, with a baseline creatinine of 1.8. We will monitor the patient’s urine output closely while hospitalized. We anticipate more than a 2 midnight stay.” 

Final thoughts

Accurately documenting a patient’s medical condition ensures acuity is accounted for to achieve proper reimbursement and performance metrics.  It also promotes clear communication between providers and others involved in the patient’s care. A common misconception is that good documentation is long documentation. This is not always the case. In nearly all care settings, the pace of medicine has picked up. Concision is valued. Eliminate superfluous history and narrative. By focusing on word choice, you can create an effective note that conveys all important information and accurately describes a patient in a way that all members of the care team and the outside world can understand it.

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