Coding and Documentation
Improvement
Theresa Cuoco, MD, FACP
Ashley Duckett, MD
Medical University of South Carolina
2012
Objectives

Understand purpose of Utilization Review

Improve History and Physical and Progress Note documentation

Learn “buzzwords” that can improve hospital reimbursement and limit
“chart enquiries”
Purpose of Utilization Review

Hospital reimbursement is dependent upon physician documentation

Billing at the incorrect level of care is Medicare fraud

UR helps ensure patients are receiving the correct level of hospital services
based on medical necessity
Inpatient versus Observation Status

Orders must always include an “admission status”

Interqual Criteria are used by UR staff to decide “inpatient” v “observation”.
Criteria include severity of illness, comorbidities and intensity of services
needed. You are not expected to memorize these.

Rules of thumb

Any patient with hemodynamic instability at point of admission generally meets
criteria for inpatient status

If no definitive diagnosis (just constellation of
signs/symptoms), admit under observation.
Observation

Defined by Medicare as an OUTPATIENT service

Typically limited to 48 hours (but occasionally can be longer)

Room and board charges are billed at an hourly rate

Hourly rate does not start until order to admit to observation is entered in
CPOE

If you aren’t sure, ask the AOD, your attending or call Utilization Review. If
this is not possible, admit as observation.

It is easier to convert to inpatient then to change to observation.
Key Messages

UR staff and hospital coders can only use what's written in the chart so be
clear and thorough in documentation

Use "observation" status for hemodynamically stable patients without a
clear diagnosis.

All H and Ps must include a family history and at least 10 systems
documented in ROS

Use buzzwords like "sepsis", "encephalopathy", and "respiratory failure" to
make sure patient acuity is accurately represented and to cut down on chart
inquiries
Observation

Emergency room:



Patient’s condition must be resistant to at least 4 hours of ER treatment
 Pain, dehydration, nausea/vomiting
If you expect at least 6 more hours of observation, it’s reasonable to “observe” in
the hospital
Clinic admissions:

Most direct admits from clinic (or home) should be observation status
Patients can “convert” to inpatient if their acuity increases (UR will let you
know!)
Inpatient Vs. Observation

UR staff completes admission review every 24 hours on observation patient
to monitor for changes in acuity

There must be daily documentation to support the need for observation services
 Do
not change the admission status order
without the direction of the UR staff
History

Chief Complaint must be included

History: Comprehensive requires: 3 of 3 elements - HPI, ROS, PFSH

HPI: 4+ descriptors or status of 3+ chronic problems
 Location, duration, quality, severity, timing, modifying, signs/symptoms
 ROS:



10+ systems are REQUIRED
Unacceptable ROS statements: “10 systems reviewed,” “Extensive” (without
elaboration)
Acceptable ROS statements: “All others negative,” “All others reviewed and are
negative,” and “All others unremarkable,” with at LEAST ONE ROS documented
Can’t double dip – if using for HPI can’t use for ROS
History
 Past
Medical, Family, and Social History: All must be
present
 Unacceptable: Noncontributory, unremarkable, or
negative

Acceptable: Family history reviewed and not pertinent (IF you
reviewed it)

Smoking cessation: Document counseling if smoked within the last
365 days
 Especially if admitted for PNA, ACS, or CHF
Physical Exam

1997 Multi-system Exam: Need 9 systems with 2 bullets each
Constitutional: 3/6 VS, Genl
Gastrointestinal
Eyes
Geniturinary
ENT
Lymphatic
Neck: trachea, thyroid
Musculoskeletal: strength &
tone, ROM, inspection, c/c
Respiratory: NEED 2! Effort,
percussion, palpation, auscult
Skin: inspect, palp
Cardiovascular: pulses,edema
Neuro: CN, DTRs, Sensation
Chest (Breasts)
Psychiatric: insight, orient,
affect
Physical Exam Tips

Anything < 9 systems with 2 bullets each down codes to level 1

Neck-supple: Counts as musculoskeletal

Extremities: No clubbing, cyanosis, or edema: MSK/CV/Skin

Unacceptable: Rest of exam negative

If patient refuses exam can’t bill higher level

Make sure to document decubitus ulcers present on admission and whether
patient has chronic indwelling catheter at time of admission
H&P Tidbits…

No family history: down codes to straightforward or level 1 H&P

Less than 10 ROS: down codes to straightforward or level 1 H&P

A straight line drawn down ROS boxes does not count!

Be honest! When using all others negative with ROS make sure you actually
ask the questions – it takes less than 5 minutes

MAKE SURE YOUR NOTE IS TIMED BEFORE THE ATTENDING’S NOTE
Bouncebacks

Acceptable to use if patient admitted within last 30 days.

Always photocopy old H&P and place in new chart

Document “PFSH, meds, allergies: REVIEWED AND UNCHANGED” – must include new ROS

Need to document that this is NEW PROBLEM or NEW EXACERBATION and not ongoing
treatment from last admission or both admissions will be “bundled”

Reminds us to document “stable or resolved” at time of discharge

Document if someone was noncompliant with their treatment plan

AMA should be utilized if patient is truly not ready for discharge
Subsequent Care Visits
The Silly Stuff

Date and time your note… Including the YEAR!

NEVER EVER use “No acute events” under subjective. Coders see this and
may down code to the lowest level.


INSTEAD give pertinent HPI and ROS (“Cough mildly improved, still SOB. No CP”)
Always think every day… Why does this patient need to remain hospitalized
and document that reason in your note.
Documentation
Improvement
Documentation Improvement

Supports medical necessity

Severity of Illness

Quality Reporting

Correct ICD-9 Coding
Documentation Basics

Document diseases not signs and symptoms whenever possible


i.e. “suspected,” “probable,” or “likely” gram positive bacterial pneumonia
Indicate acuity even when obvious

i.e. congenital, chronic, acute on chronic

Avoid “multiorgan failure” and list each organ

Document SIRS when present

>2 of following: WBC >12K, <4K, or >10%bands; Temp >101 or <96; P >90, RR>20
Sepsis

“Systemic” diagnosis more important than local

i.e. “Sepsis secondary to urinary source;” NOT UROSEPSIS

Whenever patient meets criteria for SIRS with evidence of infection, SEPSIS
is present!

Try to document from time of admission otherwise it looks like it occurred
during hospitalization
Pneumonia

CAP = Gram positive bacterial pneumonia (confirmed or suspected
irrelevant – you are treating for it)

HCAP/HAP/VAP = Gram negative or MRSA bacterial pneumonia – again, you
can document this is suspected, because this is what you are treating for.
Respiratory Failure

Document “chronic respiratory failure” with anyone on chronic O2 at home

If patient comes in with COPD exacerbation document “Acute exacerbation
of chronic respiratory failure.”

If newly requiring O2 in hospital document “acute hypoxic respiratory
failure”.
Encephalopathy

Avoid “AMS” or “altered mental status” or “acute confusion” for patients
that are altered or delirious

Use “encephalopathy”

Metabolic encephalopathy (electrolytes)

Toxic metabolic (Drugs)
Alcohol and Narcotics

Acute alcohol withdrawal patients


Document suspected thiamine deficiency if patient is getting vitamin
supplementation during hospitalization
Patients on chronic narcotics

Document “narcotic dependence” – this is not synonymous with “narcotic abuse”
Kidney Disease

If patient has “”The abrupt (within 48hours) absolute increase in serum
creatinine of ≥0.3mg/dl from baseline, a percentage increase in serum creatinine
of ≥50%, or oliguria of less than 0.5ml/kg/hour for more than 6 hours” then
document ACUTE RENAL FAILURE (instead of renal insufficiency)

Document “CKD” and Stage

Stage 1 GFR > 90

Stage 2 GFR 60-89

Stage 3 GFR 30-59

Stage 4 GFR 15-29

Stage 5 GFR <15
Congestive Heart Failure

Acute/Chronic or Acute on Chronic

Systolic or Diastolic or Combined

Core Measures:

1. Document LV Systolic Function or schedule an echo

2. ACE I/ARB given unless contraindication

3. CHF Discharge Instruction Sheet must be given

4. Smoking cessation
Skin Ulcers

Document at time of admission! You must do a full exam and document that
they are present. Wound care nurses are very helpful.

Give SIZE and STAGE:

1 Intact skin with non-blanchable redness

2 Partial thickness loss of dermis or intact or open blister

3 Full thickness tissue loss

4 Full thickness tissue loss with exposed bone, tendon or muscle

Unstageable – full thickness tissue loss with base covered by slough or eschar
Diabetes

Uncontrolled: A1C>7

Goal: blood sugars <200 within 24 hours

Document diabetic complications





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Retinopathy
Autonomic neuropathy
CKD/nephropathy
Neurogenic bladder
Gangrene
Coma
Ulcer
Anemia and Nutrition

Anemia: be specific as to the etiology whenever possible (ie acute blood loss
anemia)

Morbid obesity – document this when BMI> 40

Malnutrition:
Type of Malnutrition
Weight Reference
Albumin
Weight Loss
Mild
BMI 17-18.4
3.2 to 3.5
<10% weight loss
Moderate
BMI 16-16.9
2.5 to 3.2
10-20% weight loss
Severe
BMI <16
< 2.5
˃20% weight loss
Palliative Care

Document “palliative care” if still actively treating medical conditions

Document “comfort care” if not still actively treating medical problems

This will ensure that patients at end-of-life are not assessed for compliance with
quality measures
These are considered “Hospital-Acquired
Conditions” if not “Present on Admission”
Therefore you must document these on H & P:
DVT/PE
Manifestations of poor glycemic control
Vascular cath infection/clot
Fall/trauma/fracture/dislocation
Cath-assoc UTI
Pressure ulcers
Surgical site infections
Diagnoses that are “ruled out”


Often we treat for suspected diagnoses that are later ruled out

Ex – Treating for “bacteremia” in a pt with GPC on gram stain, later found to be
coag-neg staph.

Ex – Antibiotics are given for pneumonia in the ER, but it is determined that
patient does not have pneumonia and they are stopped.
If you don’t document that the diagnosis was “ruled out” than the coders
will code and bill for that diagnosis
Final Words…

If you didn’t document it, you didn’t do it.

Date (month/day/year) and time your notes.

Choose your words wisely. Level of care and thus reimbursement is based
on what you write.