Here is a classic example of the ridiculous documentation that hospitalist and hospital based medical care has become. I say every day that 80% of what I document has nothing to do with taking care of patients and everything to do with making sure that income is maximized and for protection against allegations of fraud.
In this example below, I remember documenting that a patient had oxygen dependent COPD. There were some dramatic changes in 2008 to the inpatient prospective payment system (IPPS) that defined how hospitals get paid by Medicare. The over 800 diagnosis related groups (DRGs) now carry modifiers for Medicare Severity-Diagnosis Related Group (MS-DRG) Medicare has a list of disease states that will increase hospital payments based on whether the primary DRG diagnosis also carries a complicating condition (CC) or major complicating condition (MCC) that determines the MS-DRG.
If a physician can document, in the official chart, that you the patient, have one of these several hundred Medicare defined MCCs or CCs, then your hospital can collect extra money. It's not chump change. It can run into the millions of dollars a year. I've seen some simple data and have extrapolated, in my mind, what the potential hospital income could be if all doctors cooperated with this madness. The dollar: documentation ratio is phenomenal. A little physician effort is worth millions to the hospital's bottom line. As a physician, instead of bitching about it, just document the truth according to Medicare and you might help your hospital pay for a brand new doctor's lounge or maybe even help pay doctors for being on hospital call.
Every smart hospital in this country has hired nurse specialists to sift through hospital charts looking for evidence of diseases that, while documented, are not documented in a way that allows for an MCC or CC to be submitted when it comes time for the Medicare National Bank to pay up. It's all perfectly legal. In fact, if you're a hospital and you haven't implemented this type of program, you're going to lose the game. CMS knows this. In fact, they've even accounted for this by reducing their increased severity of illness adjustment payment to account for an expected improvement in physician documentation compliance. In other words, CMS says they are going to pay you more, but not as much as you would expect because you're going to be better at playing the game. It all just sounds so silly, doesn't it?
So it is. It is what it is. This is what inpatient medical care has become courtesy of people y'all voted in. It's one of the hospitalist advantages that many administrators don't factor in when they balk at paying $100,000 a year in hospitalist subsidy. Trust me. A hospitalist service that understands this cooperative effort can make a hospital more than 10x that amount by following these robot documentation rules. This is how you run a hospitalist program. This is how not to run a hospitalist program.
Does me writing chronic respiratory failure with continuous home oxygen use required instead of O2 dependent COPD annoy the Hell out of me? Not one bit. It is a waste of my time and offers no benefit to the patient care. But it is what it is. I've come to accept that as a major part of my daily existence as a hospitalist. Most of what I do on a daily basis is a waste of time. Until we change the way we pay for health care, this will always be the case.
The future is not going to be pretty. We got exactly what we paid for in Medicare. In America, we have to pay nurses north of $60,000 a year in salary plus benefits to round to round on patient charts in order to make sure we can collect more money to pay for more nurses to round on more charts.
This is comedy at its finest, if it wasn't so sad. I would like to take this opportunity to formally welcome the millions of new Medicare Baby Boomers who will enter Medicare's Comedy Central this year. Good luck. It's five -o-clock some where and there's a hospitalist just waiting to welcome you to your new home.
For more information on hospitalist salary, visit
For more information on hospitalist salary, visit
- Hospitalist compensation salary survey 2010 (SHM/MGMA) based on 2009 data
- Hospitalist subsidy and support payments update for 2011, based on 2010 data.
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