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Language is key in clinical documentation
Sepsis by another name doesn't code the same
When Stony Brook University Medical Center presented an educational program to its urology staff about the importance of using the correct terms in documentation, the physicians pointed out that in medical school, they learned to write "urosepsis" on the chart for patients who had developed sepsis from a severe urinary tract infection, according to Catherine Morris, RN, MS, CCM, CMAC, executive director of care management and clinical documentation improvement administrator at the 591-bed regional hospital in Stony Brook, NY.
However, if a physician writes "urosepsis" on the chart, it codes out to a urinary tract infection, which is not enough to meet admission criteria for a hospital stay. In addition, it skews quality data if it appears that patients are dying of urinary tract infections. "Instead, physicians should write `sepsis due to a urinary tract infection,' which is codable as sepsis and indicates that the patient is critically ill and has a high risk of mortality," Morris says.
Coding guidelines don't use the same information doctors learned in medical school and coding language doesn't match with medical language, says Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY. "We have to transition physician documentation to accurately reflect the complexity of the patients and to make sure the documentation contains the appropriate language so the coders can use the correct code. This presents a challenge to the clinical documentation staff and to physicians as well."
Doris Imperati, MSN, MHSA, CCM, associate director, Navigant Consulting, a consulting firm with headquarters in Chicago, says, "When they examine patient charts, clinical documentation specialists should look for the nuances in the physician's language and the notes from other clinicians for hints that the physician documentation may not be complete. Medicare rules say that coders can't use documentation from nursing, physical therapy, or any other clinician who is not a licensed provider and is giving hands-on care. They may use documentation from nurse practitioners and physician assistants but if there is a report from a radiologist who is interpreting a test, they can't use that. However, documentation improvement specialists can read the nursing progress notes or chart notes from the nutritionists, the physical therapy, or other ancillary staff and use that information as prompts to query the doctor," she says.
For example, if you read in the nurse's notes that a pneumonia patient has a decubitus ulcer, but the physician didn't document it, query the physician as to whether he concurs with the nurse's note and, if so, write it in the chart in order to capture the acuity. Imperati says, "Doctors are likely to be concerned about treating the pneumonia, and the skin problems are of secondary importance to them. However, if a patient with pneumonia has bed sores, it will take more resources to care for that patient and if the decubitus stage and location are documented, it will add a CC [complication or comorbidity] or a MCC [major complication or comorbidity] to the DRG, which increases both the approved length of stay and the financial reimbursement. Heart failure is another case in point. The term 'heart failure' is a broad one, and physicians have to document it carefully and completely, in order for the hospital to be paid appropriately."
For the hospital to be paid appropriately, the physician has to document what kind of heart failure the patient has (systolic, diastolic, or a combination of the two, or rheumatic heart failure) and whether it's acute or chronic. "If the physician just writes 'heart failure,' the coder doesn't know what it really means and has to assign a code with a lower reimbursement," Imperati says. "Heart failure as a second diagnosis can result in adding a CC or a MCC to the DRG. A lot of elderly patients have some elements of heart failure, which means that documentation specialists should look carefully at the charts of Medicare patients to see if there are hints that heart failure is a comorbidity."
For example, if a patient comes in with pneumonia, and the physician orders IV Lasix and/or an angiotensin-converting enzyme (ACE) inhibitor, take the opportunity to query the physician and ask, "This patient was admitted with pneumonia and is also being treated with Lasix and an ACE inhibitor. Please document the diagnosis associated with this treatment."
Imperati says, "Chest pain is a symptom, not a diagnosis, and the underlying cause should be documented." It doesn't matter how many CCs or MCCs a patient has, if the principal reason for admission is chest pain (MS-DRG 313), the expected length of stay is 1.7 days. "Many patients who are admitted with chest pain stay longer for additional work up to determine the underlying cause," she says. If the underlying cause of chest pain is related to an acute episode of heart failure, the physician should state it in the chart, which will bump the expected length of stay up to 2.8 days. "Otherwise, the insurance company will expect the patient to be discharged in 1.7 days," she says, adding "the hospital's publicly reported data will be more accurate and reflect better outcomes if the suspected etiology of chest pain is documented, rather than just the diagnosis of `chest pain.' Malnutrition, especially in oncology patients, represents another opportunity for improvement in documentation and reimbursement. These patients often have nutritional issues due to the cancer themselves, as well as due to the treatments which cause nausea, vomiting, diarrhea, loss of appetite, and weight loss."
There are three levels of malnutrition: mild, moderate, or severe, which translate into a CC or an MCC, which can be evaluated through laboratory values of pre-albumin, serum protein, serum calcium, and serum albumin.
Imperati says, "Malnutrition, when described as severe, is a MCC, but if the doctor writes 'undernourished,' it doesn't count for anything in coding language. The nurse may write that the patient is frail and thin. The nutritionist may write 'protein calorie wasting', or the doctor may document cachexia. These all are indications that the clinical documentation specialist should look at the laboratory values, weight loss, and other factors and ask the doctor for more specific documentation regarding the patient's nutritional status."
A diagnosis of pneumonia does not necessarily translate as simple pneumonia. It might be a respiratory infection that has a higher length of stay and better reimbursement. Bacterial pneumonia is simple pneumonia, but if the doctor specifies the organism, such as "klebsiella pneumonia," the diagnosis is more serious and qualifies as a respiratory infection.
Imperati says, "Sometimes the doctor can't specify an organization but can say he suspects gram negative pneumonia, which is difficult to treat and uses more resources. This can be coded as a respiratory infection."