Guest Post: Use case managers as effective CDI tools in the emergency room

by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS

I work at a small community hospital with less than 100 beds. We implemented an emergency department (ED) case management (CM) model that focuses on weekday admissions during regular business hours. We’ve trained the ED nurse supervisors to carry out the basic tenets of case management — insuring proper patient admission status and assisting the patient and family as the navigate the maze of the healthcare delivery system.

But we also were successful in getting the ED physicians interested in clinical documentation improvement (CDI) because both the physicians and the ED director realized that establishment of medical necessity and accurate reporting is predicated on sound, effective documentation techniques that best capture patient acuity.

A recent case highlights a potential role of the ED case manager in CDI-related tasks.

A patient presented to the ED in acute respiratory distress with likely chronic obstructive pulmonary disease (COPD) exacerbation. The physician ordered a chest x-ray, which indicated a right lower lobe infiltrate in addition to pulmonary vascular congestion and cardiomegaly.

The patient history  revealed that local police went to the patient’s home after a family member called authorities worried that the patient had not answered the telephone for three days. The police found the patient on the ground, unconscious in their home.

The patient received a dose of Zosyn and Rocephin in the ED in addition to IV Lasix 40 mg. The physician decided to place the patient on a Bilevel Positive Airway Pressure due to the following conditions:

• Patient’s saturation of oxygen was 70% on four liters oxygen and increased work of breathing
• Patient’s respiratory rate was 42 with accessory muscle use and obvious retractions
• Patient remained unresponsive

The physician intended to intubate the patient, but the patient’s sister expressed wishes to keep the patient off a vent. Final clinical impression in the ED was as follows

• Acute exacerbation of COPD
• Acute respiratory distress
• Hypoxemia

Notice the last two diagnoses include symptoms that do not reflect heightened patient clinical acuity whereby the patient was subsequently admitted to the intensive care unit (ICU). When the ED case manager reviewed this case with the physician he was able to discuss the acuity of the case with the physician positively affected documentation of clinical acuity as follows:

• Acute respiratory failure with COPD exacerbation, likely aggravated and precipitated by aspiration pneumonia acute exacerbation of CHF

This clinical documentation supports an admission to the ICU. It more accurately reflects the physician’s clinical judgment, medical decision-making, and concerns for morbidity and mortality. The documentation also assists physicians in the business of medicine by reporting life threatening clinical conditions in support of the critical care billing for.

A strong CM and CDI presence in the ED will lead to fewer medical necessity denials. ED case managers ensure help physicians understand and meet medical necessity requirements and the CDI specialists ensure the physicians’ documentation supports that decision.

Editor’s note: This article originally appeared in our sister publication The Case Management Mentor. Krauss, at the time of this article's release, was Executive Director of the Foundation for Physician Documentation Integrity.