It’s not exactly a secret that the transition from fee-for-service to value-based care has caused a lot of headaches and heartaches among CFOs and revenue cycle professionals at hospitals and health systems. It isn’t so much the destination that worries them; it’s surviving the journey that keeps them up at night.
As we’ve discussed before, one way to offset the loss of revenue from services is to do a more competent, thorough job of coding and billing overall—so you can alleviate unnecessary, avoidable self-inflicted denials. After all, just because you bill for something doesn’t mean you will be paid for it – and even if you are, that doesn’t mean you’re safe from financial recoupments!
This is even more important today, where everything centered around claims is being scrutinized more carefully. One little mistake or oversight can have huge consequences, for the patient as well as the hospital or health system.
I can attest to that fact—from personal experience. I recently went in for a screening, one that I’d put off for a while. Someone at my health system must have really been focused on care gaps because they nagged me until I finally went in.
Everything went fine – at least until I received the bill. Instead of the $250 I was expecting, I was looking at a bill for $4,000. You can bet I was on the phone as soon as I recovered from the shock of such a high charge.
It turns out that the way I’d answered my doctor’s questions had led him to document the planned screening as a diagnostic procedure, not a simple screening – or at least, that was the way the coder assigning an ICD-10 code interpreted the documentation. My doctor didn’t think anything of it, in part because he likely wasn’t even aware of the significant financial impact it would have on the patient, namely me.
This is one of the challenges of clinical documentation improvement (CDI) – the “integrity of documentation” reflective of the physician’s clinical judgment, medical decision making, and thought processes that serve as the foundation for clinical facts, clinical content and context, followed by convincing physicians and other hospital personnel to understand the impact of what I call the three I’s: Incomplete Information, Inaccurate ICD-10 Coding and Insufficient Documentation. Each of these I’s can materially affect both patient satisfaction and the revenue cycle. So just like a disease, the earlier you can identify any of these elements, the easier they are to treat.
Of course, physicians in a hospital setting don’t necessarily think about the business side of medicine – there are whole departments responsible for that! These physicians are focused on patient-care outcomes, management of chronic as well as acute conditions – as they should be. Witness the results of a survey led by researchers from The Dartmouth Institute for Health Policy and Clinical Practice which found that while the overwhelming majority of physicians surveyed (92.2%) felt that doctors had a responsibility to control costs, less than half of the physician-respondents (36.9%) reported having a firm understanding of the costs of tests and procedures to the health care system. Furthermore, approximately one-third of physician-respondents felt it was unfair to ask doctors to be both cost-conscious and concerned with patient welfare, and approximately one-third also say they try not to think about costs during treatment decisions. (And not surprisingly, about a third stated that doctors are just too busy to worry about costs.)
This doesn’t change the fact that it’s vitally important to change that perspective – to elevate the understanding of how the two “sides” of healthcare are intertwined.
With that in mind: Here’s how CDI can be used to alleviate three I’s, while also reducing preventable denials and ensuring health systems are reimbursed properly and fully for the high-quality, medically necessary care they provide.
#1: Inaccurate Information
One of the biggest sources of incomplete information is the disconnect around defining medical necessity. Following the example above, the physician may order and/or provide (with the best of intentions) a diagnostic workup or therapeutic treatment, yet not provide all the clinical context and thinking as to why the intervention is required. The end result? A clinical intervention that is reported to and perceived by third-party payers as not medically necessary under the reasonable and necessary standard of care. The majority of medical-necessity denials are truly avoidable, requiring only the “complete, concise, and consistent” clinical information documented by the physician and demonstrating their substantive clinical rational.
Physicians can benefit from a deeper, richer understanding of what “medical necessity” is in the eyes of the CMS or commercial payers – not so they follow a different course of care, but so they make best use of their time and enhance patients' experience navigating the health system. It’s also important for providers to understand that just because they have a CMS Advanced Beneficiary Notice (ABN) signed by the patient, that doesn’t necessarily mean the hospital will ultimately be paid. The one doesn’t simply lead to the other – in part because patients are inclined to sign whatever they’re presented with when in need of care, and in part because the call is ultimately CMS’, not the patient’s.
Inaccuracy can also arise from clinicians including unnecessary information in the electronic medical record (EMR). The EMR is meant to capture what’s relevant – thus, physicians and their organizations are best served by focusing on what’s clinically important so that the true picture doesn’t get lost in an avalanche of the trivial details. (Often, the source of these is cut-and-paste and carry-forward documentation practices—which lead to the inclusion of non-relevant details from previous encounters or care episodes.)
#2: Inaccurate ICD-10 Code
Physicians or coders will often use the code they think they should use based on past experience – not necessarily a bad thing, but a practice that does have risks. In other instances, it may be that they are overly dependent on a coding tool – and may not always interrogate whether the resulting diagnosis code actually represents the diagnostic information provided by the the physician in his/her submitted order. This has become a bigger problem since the transition to ICD-10, a change that in some cases has led to increased “overcoding” where the ICD-10 code assigned by the coder is not congruent with the supplied information.
Obviously, if the diagnosis as provided in the order doesn’t support the ICD-10 code there is a high likelihood the claim will be denied. This in turn leads to the hospital or health system having to manually review documentation after the fact to determine the correct code and resubmit the claim (if the denial is appealable). And that translates to expending unnecessary labor resources and associated costs while seeing payment further delayed.
That’s not all, however – these errors can also lead to potentially expensive fines. One of the best coding doctors I ever met was a guy in Colorado. He just knew how to do everything exactly right – it was amazing. His gifts extended far beyond the practice of medicine.
When I asked him how he got so good, he told me that he’d paid $1 million for a world-class but ultimately painful education – in the form of Medicare fines related to submission of bills not supported by his documentation in both the hospital and office setting.
Getting physicians to understand the compelling argument for accurate and complete information is critical to any hospital or health system’s success. It’s a lesson no one should have to learn the hard way. CDI and associated supporting technology can help in this effort by uncovering potential discrepancies and suggesting alternatives that are more in keeping with the information at hand. Technology + expertise can also illuminate where the information gaps most likely exist – so they can be effectively addressed in a proactive rather than reactive fashion.
#3: Insufficient Documentation
In simple terms, this occurs when physicians have made the correct diagnosis, supporting the assignment of the correct code – but haven’t included the “rest of the story” in the EMR. In fact, the advent of the EMR may contribute to this challenge. Notes that previously appeared in a handwritten patient chart are left out of electronic documentation – for many people, physicians or not, it’s just less natural to jot down thoughts when typing vs. writing by hand.
As mentioned above, it’s vital not to muddle the meaningful details with trivial asides – but relevant specifics can be quite valuable, especially in terms of saving time if the payer requests additional information.
Another issue that can arise: information entered into the EMR, but in the wrong place. For example, critical information that should be in the fixed fields is instead in the free-text notes, where it might go unnoticed by coders. Or a physician might enter the title but not fill in the description. Or, they’ll fill in a description but not break it out properly. When any of these situations occur, again, denials will rear their ugly heads – or, in the best case, the coder will expend additional time trying to piece it all together.
Articulating the importance of including all documentation, including notes, lab results, X-rays, MRIs and other information that supports the diagnosis is the foundation of an effective CDI program. The more of the right information the physician provides, the more likely the claim will be reimbursed correctly – the first time. The bottom line is the physician’s inclusion of clinical judgment, medical decision making, thought processes and clinical rationale in his/her documentation will play a big role in the coder’s ability to accurately capture the most clinically appropriate ICD-10 code in support of medical necessity. And the results of that? Fewer unnecessary denials, less rework, and patients who are more satisfied with their overall care experience.
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