ICD 9 Coding And Documentation Can Make Or Break Hospital Finances

More changes to the  PROPOSED FISCAL YEAR 2009 PAYMENT, POLICY CHANGES FOR INPATIENT STAYS IN GENERAL ACUTE CARE HOSPITALS  mean you need to document your really sick grannies with "severe" sepsis as  whether they were on a ventilator for more than 96 hours or less than 96 hours.  As I learned previously that our coders aren't allowed to assume anything,  I interpret this to mean that if a patient of mine is on a ventilator on May 1st, 2008 due to severe sepsis, and they are still on the ventilator on May 7th, it is not enough for the coder to add up the  hours.  I take this to believe  that unless I write in my progress note:  "Severe sepsis on a ventilator more than 96 hours", I will assume that my hospital is losing a higher DRG payment rate.  Don't forget, I have to include the word "severe" in my definition of sepsis.      

I must also write whether the patient has a major complication or comorbid condition (MCC).  I have to do this in addition to documenting the required components for the Medicare National Bank chart police--whether I code a CPT® critical care code 99291 or 99292,  or a CPT® hospital follow  up code 99231, 99232 or 99233.  And I have to do all this, while trying to save nana's life.  Here are some of  the proposed changes:

Proposed Changes To The MS-DRG Classification

The proposed rule would insert the words “or severe sepsis” after “Septicemia” in the titles of the following MS-DRGs that became effective October 1, 2007 (FY 2008):

• MS-DRG 870 Septicemia with Mechanical Ventilation 96+ Hours
  
• MS-DRG 871 Septicemia without Mechanical Ventilation 96+ Hours with MCC
• MS-DRG 872 Septicemia without Mechanical Ventilation 96+ Hours without MCC
  
  
  The following, in its entirety sums up, to perfection, what this all means for ICD 9 coding and documentation.

Physician documentation Seen as Crucial

Kruse sees compliance and reimbursement as hinging on two fronts. "Physicians have to rise to the occasion, or hospitals will lose money. This will require a lot of physician education because physicians are used to documenting without much specificity," she says. "Coders are required to code to the highest degree of specificity, but that" can't happen without quality physician documentation.

For example, Kruse says, physicians often think it's good enough to document "congestive heart failure" (CHF). But with MS-DRGs, they need to indicate the type of CHF — right-sided or left, systolic or diastolic, etc. Documentation of "CHF" (ICD-9 code 428.0) is not a reimbursable CC, she says. And when documenting chronic renal failure, CMS has placed only ICD-9 codes 5854 and 5855 (chronic kidney disease stage IV and V) on the list. Chronic kidney disease unspecified (code 585.9) is not on the list, she notes.

CMS assumes hospitals will adapt coding and documentation to capture severity of illness and thus get paid more under MS-DRGs (though not because patients are actually sicker), Kruse says. So even though the IPPS proposed an across-the-board 3.3% payment update for fiscal year 2008, most hospitals won't actually receive that much. This is due to CMS "proposing an adjustment to eliminate the effect of coding or classification changes that do not reflect real changes in case-mix," the rule states. The amount: 2.4% for both fiscal year 2008 and FY 2009. This is necessary to keep the Medicare budget neutral, CMS says.

"If you raise your level of coding and documentation, depending on the severity of illness of your patients, you may receive the entire 3.3%," Kruse says. But if you don't code and document better, it is likely that your hospital will not receive any of the market basket increase, and instead will see an overall reduction in payment when compared to previous years.

What's in it for the docs?  Well, unless you are a hospitalist,  nothing.  You have no aligned incentive with the hospital to be a good documenter.  You could care less if the hospital gets their extra money for writing a good essay, for throwing in some key words here and there.  I can understand that completely.  Why spend 20 minutes documenting correctly simply so some other entity can get paid more, when you can spend 5 minutes and not care about it.  Plus, you don't get paid to spend 20 minutes.  You get paid on volume.  As a hospitalist,  great documentation by following the rules  is important, because how I document directly affects how much money the hospital can collect,  and that increases the value I  represent  to the hospital.  Money is the name of the game.  It has no bearing on patient outcomes.  It is a giant data gathering expedition by the policy makers paying the bills. And they are making physicians do it for free.

I find it interesting that the RUC authors of the Medical Home Model suggested that complexity of free medical care for patients does not correlate with the number of  multiple chronic medical conditions.  That the Medical Home Model, should instead, be tiered according to practice characteristics.  So the question I have is,  why couldn't patients, with complicating or cormorbid conditions, as declared by the hospital payment system, apply to outpatients as well.  If they can declare stage 4 or stage 5 kidney disease a MCC that pays a higher rate for hospital care,  why not for out patient clinical care?  Why have we left the patient characteristics out of the equation entirely in terms of patient care.  I simply don't get the rational.  Patients with advanced heart failure or kidney disease or diabetes are much more complicated and time consuming to care for.  To not include them in the equation for time and money for primary care is like taking a beat up rusty truck to a paint shop and demanding they quote you the same price for a paint job as a 2007 BMW with a tiny scratch on it.  It makes no sense, both in time and resource utilization.

How does the patient benefit in all this hogwash?  Does the patient care?  Not in the least.  They could care less how you write your note.  But,  they are last on the hierarchy of importance when it comes to 1) Money 2) Legal considerations 3) Documentation 4) And finally patient care.  The rules have pushed the patient to the back of the line.  It's really quite sad.  And it's why change must be a unified force with doctor and patient aligned on the same front, driving the change.  The only two important players are getting squeezed to death by forces that mean nothing to good patient care.  And we sit by in neutral while those with power and money make all the decisions for us.

You can see much more in my free lectures on medical billing and coding.

Go here where I explain ICD and CPT codes.

Go here where for sensitivity and specificity explained.