Can a Program to Improve Clinical Documentation and Coding Secure Appropriate Assignment of Patient Status and Elimination of Medicare Penalties for Readmission

Questions are being raised about the validity of Medicare’s 30 day readmissions data currently being reported coincidental with the penalties for hospital readmissions rising from 1% of total Medicare funding based on how many patients returned for care within 30 days to 3%.  These are serious detriments to hospitals’ declining margins.  Heart failure, heart attack and pneumonia are the three leading diagnostic categories that are being used as the hammer to reduce preventable readmissions in the Patient Protection and Affordable Care Act.

CMS is citing a drop in readmissions while at the same time the number of patients being seen and held in observation is exploding coincidental to the reduction in readmissions.  HSMN consulted experts in this field and they tell us that a combination of high rates of Medicare payment denials and aggressive auditing on short hospital stays are at the very center of the reduction in readmissions.  Clinicians in well-known hospitals question whether admitting these patients to observation and performing the same tests as they would have as inpatients and then sending them home is compromising patient care.

Clearly the management of patients post discharge is critical to their staying well but there is another important factor to be considered.  How well has the patient’s initial admission been managed?  Have the team members really focused on a plan post discharge and are their efforts clearly reflected in the clinical documentation?  Has the problem list been directly addressed by each discipline so that a “Complete Picture of the Patient” emerges, a picture that leaves no doubt about diagnoses, intervention and post discharge plan. 

HSMN has consulted a number of Clinicians of all stripes and found upon review of records by Medicare audits that the clinical documentation was lacking to support the readmission.  The coding of the case was also off and easily allowed the audit to disallow readmissions.  CMS has perfected the art of “taking the people’s money back” meaning of course our tax dollars and few are prepared for the audits that ensue.

After our brief study of three Hospitals and a documentation and coding review, we found that critical elements were not documented and the coder did not have every data element needed for a support of the readmission.  Based upon our findings and client input, we have determined that a new kind of internal auditing and monitoring of the clinical documentation could make a huge difference in the reimbursement, as well as in the care.

Our Physician Advisory Group and Senior Clinical Documentation Specialists/Coders have combined to work closely on a solution.  The Cardiologists and the Pulmonary Specialists have joined with the Senior Coders to begin a prospective analysis of the clinical documentation with a complete focus on the integration of care reflected in the documentation of care. 

The Clinical Documentation Specialists helped the Clinical staff to translate what they were doing and thinking into clinical documentation that would support the readmission based on the evidence.  In other words, there was no way to avoid a readmission based upon the documented condition and the care provided in the previous admission.  It means that a Clinical Team must work closely with a Documentation Team to make sure all of the care and the documentation are completely integrated.

After many cases and hospitals, HSMN has created a model in which the Clinical staff, the Coding staff and the IT staff work to assure that what is documented is what has happened to the patient during this admission and that there is clear pattern of integration. 

Hospitals and their Medical staffs can begin to expect these surveys and audits to increase.  Once ICD-10-CM is introduced, the Medicare Audit Teams will have more elements by which to judge care.  Based on the experience that HSMN has gathered in collaboration with its clients, a model has emerged which addresses the current state and navigates the Clinicians and the Clinical Documentation/Coding staff to the ICD-10-CM world.

For more information about this program please contact HSMN on our website or via email