Exploring records for medical necessity
June 25, 2012
CDI Blog - Volume 5, Issue 26
Coding isn't just about reading documentation and selecting codes based on certain words. It's about processing information and assessing whether the codes reported accurately depict the clinical picture and medical necessity for an admission.
While CDI and coding staff members are well versed in assigning a principal diagnosis, they are often less adept at incorporating the concept of medical necessity into their practices, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS. Coders tend to simply code what's in the record rather than determine which conditions actually justify the services performed, says Krauss, an independent HIM consultant in Madison, WI. And CDI specialists frequently stop reviewing records once they've captured their CC/MCC quota.
Miscommunication mishaps
When a facility neglects to capture codes which reflect the medical necessity of an inpatient admission (some of which criterion may be payer-specific) it can result in denials, says Krauss. But reporting codes simply to satisfy medical necessity—when physician documentation doesn't justify doing so—can also be problematic, he says.
This is perplexing for inpatient coders. Although certain conditions may help justify the medical necessity of an admission, coders can't report them unless physicians clearly document treatment (e.g., medications or diagnostic tests), says Heather Greene, MBA, RHIA.
"Just because the doctor documented the patient as having a certain diagnosis, if it was not treated during the stay ... the code cannot be picked up," says Greene, a coding and documentation consultant at Kraft Healthcare Consulting, LLC, in Lexington, KY.
Some physicians may even list problems or conditions they ultimately never treat or address, says Greene. For example, coders may find a singular reference to a urinary tract infection among hundreds of pages of documentation. Then they must determine which medications or tests, if any, were provided.
"Sometimes you see the opposite. There may be a urinalysis with positive results and Bactrim® ordered without a diagnosis listed anywhere," she says.
Krauss provides another example: A patient is admitted to the hospital with leg pain and a leg wound that is not healing. A physician suspects osteomyelitis and performs an MRI scan that doesn't reveal any signs of the condition. However, the physician doesn't rule the diagnosis in or out, and a coder reports acute osteomyelitis as the principal diagnosis with a Stage III ulcer as secondary.
"The problem is that the patient was in the hospital and didn't ever receive any antibiotics," he says. "If it's truly osteomyelitis, they're going to likely receive a six-week course of antibiotics."
Mistakes happen
Sometimes physicians make mistakes, and coders and CDI specialists are in a position to catch those mistakes, says Jessica Whitley, MD, MBA, an independent physician reviewer for Ohio KePRO in Seven Hills. In this role, Whitley validates DRGs and medical necessity. Her other work as a hospitalist at a large academic tertiary center and a small community hospital gives her a unique perspective of medical necessity.
As an independent peer reviewer, Whitley may not validate the presence of documented conditions in the absence of any documented signs, symptoms, or confirming tests to substantiate a diagnosis. The only exception occurs when physicians clearly and reasonably state their reasons for suspecting the diagnosis despite a lack of clear evidence.
"Doctors think that once they document a diagnosis, that outside reviewers may not look for signs, symptoms, and diagnostic tests to support that diagnosis," says Whitley. Physicians also may think that if testing clearly supports a diagnosis, a patient's signs and symptoms become irrelevant. However, signs and symptoms—and the diagnosis—are often what demonstrates severity of illness and justifies admission, she says.
Sepsis is an example Whitley often encounters. Physicians may document sepsis when a patient has an elevated white blood count and bacteremia on a blood culture, but vital signs and symptoms the patient describes show no evidence of SIRS (e.g., elevated temperature, tachycardia, tachypnea, altered mental status). If a CDI specialist notes obvious tests or signs and symptoms that fail to support a documented diagnosis, they should consider the possibility that the diagnosis is not present and query physicians for more information, she says.
Whitley provides an example of a nursing home patient who presents to the hospital. Nursing home documentation indicates a history of end-stage renal disease (ESRD). ED and attending physicians document a history of ESRD even though hospital laboratory work reveals a creatinine of 0.9 and a BUN of 20. These results are normal and not consistent with a diagnosis of ESRD, says Whitley.
This inconsistency between the laboratory results and diagnosis should raise a red flag, she says. The documentation is indicative of chart lore—information in previous documentation that physicians repeat without evaluating its validity. Seek clarification if something clearly contradicts a documented diagnosis, Whitley says.
Inpatient vs. observation status
Although coders don't play a significant role in determining patient status, they may be able to identify documentation that could alert case managers to scenarios requiring clarification, says Whitley.
"To doctors, inpatient versus observation status may seem irrelevant," she says. "Doctors may think that just because a patient's signs and symptoms or diagnosis may warrant some time in a hospital, then an inpatient stay is warranted, too. Doctors equate in the hospital' with inpatient."
Medical necessity is a sensitive topic, says Whitley. Ensuring physicians understand that patient status (i.e., inpatient, outpatient, observation) in no way interferes with the plan of care is important, she says.
Remind physicians that documentation can help demonstrate the medical necessity of inpatient admissions, says Whitley. Documentation should include illness severity and acuity, along with signs and symptoms, she says.
Encourage physicians to answer these questions:
- How long has the patient had the problem?
- Is it a chronic problem that can be worked up on an outpatient basis?
- Is it an acute-onset problem with a severity that requires a hospital stay?
Clarify questions of medical necessity
"I think coders have a great opportunity to educate physicians regarding the essential elements of documentation," says Whitley. Many physicians don't understand the details that reviewers scrutinize when assessing cases for medical necessity, she says.
Coders should consider medical necessity when querying in cases for which two or more conditions meet the definition of principal diagnosis, as stated in The Social Security Act, 42 USC §139y(a)(1)(A), says Krauss.
The tendency of CDI programs to focus on diagnostic specificity and not medical necessity is perplexing because of the number of medical necessity denials, says Whitley. Physician resistance could be a reason.
"Medical necessity questions seem like they are more challenging to the doctor. It seems more contentious, she says, noting that clarifying a diagnosis is not as controversial as asking whether a patient truly meets criteria for inpatient admission.
"Emphasize to physicians that clarifications regarding medical necessity have nothing to do with challenging a physician's clinical judgment," says Whitley. "They have more to do with helping physicians determine the best and most cost-effective place to provide that care."
Editor's Note: This article first published in the April 2012 edition of Briefings on Coding Compliance Strategies.