With Hospitals at Risk From Faulty Documentation, Consider Tools for MDs
Reprinted from the 3/9/00 issue of REPORT ON MEDICARE COMPLIANCE, the nation's leading source of news and strategic information on false claims, overpayments, compliance programs, billing errors, and other Medicare compliance issues. For more information on REPORT ON MEDICARE COMPLIANCE
It may be in hospitals' self-interest to subsidize the costs of transcriptionists and brainstorm other strategies to boost the quality of all documentation done by the physicians who provide hospital outpatient services.
Documentation is essential to everything you do in Medicare - from promoting compliance and quality of care to minimizing downcoding and the errors that create overpayments and may generate false claims. More exact physician charting ensures fairer reimbursement, especially under the forthcoming outpatient prospective payment system. In the eyes of HCFA and the OIG, if a service isn't documented, it didn't happen - a message with a powerful subtext.
Solutions to physician-documentation problems must target the prime weaknesses with documentation, says John Stimler, a full-time Florida emergency room physician and part-time educator/consultant. This includes the fundamental discrepancy between the way physicians are taught to think in medical school - about areas of the body (i.e., look at ear, nose and throat, then move on to lungs and heart, then belly) - vs. the way Medicare guidelines require physicians to document in terms of body systems (i.e., the entire gastrointestinal system, from mouth to rectum). Physicians also have specific documentation shortcomings, such as failing to clearly separate components of the medical record's "history" section - including chief complaint, review of systems, history of present illness, and past family and social histories.
"Right now, charts are so helter-skelter," Stimler says. "Physicians who don't document properly and don't help coders hurt themselves" - and hospitals.
If physicians improve their compliance with the Medicare documentation guidelines for evaluation and management codes used for the cognitive (or thinking) part of the service, they will benefit in more ways than one, Stimler says.
For example, coders could stem reimbursement losses due to "downcoding," which they engage in out of fear of fraud and abuse investigations.
In fact, the very nature of Medicare documentation guidelines - with their specific, objective criteria - gives physicians a defense against auditors and fraud investigators who try to claim they billed at a level or two higher than justified, says Stimler, president of The Stimler Healthcare Group.
Hospitals will potentially take a financial bath on outpatient PPS if they don't help physicians repair documentation. Outpatient services are a bigger and bigger piece of the hospital revenue pie.
In the past 15 years hospitals have expanded outpatient services to counter the loss of inpatient revenue resulting from the advent of the inpatient prospective payment system and its DRGs.
Now here comes outpatient PPS with its ambulatory payment classifications (APCs), and there's nowhere else to look for more income. So hospitals need to bill and document more accurately. No matter what, APCs will take effect, as Congress mandated, by July, 2000.
If the documentation by physicians who provide care on the outpatient side (emergency room physicians, cardiologists, gastroenterologists, urologists and/or plastic surgeons) doesn't improve, "then hospital outpatient revenue will potentially plummet," Stimler predicts.
Documentation weaknesses "will become a much more acute problem with APCs," he says. Hospital coders who do the facility fee component will have to carefully select an APC code that closely matches a physician coder's choice of CPT code (part of the HCPCS codes used for physician procedures). Documentation must be precise for both sides of the table.
"Hospitals will have to rely on the physician's charting capabilities to ensure their coders choose a code that coincides with the level the physician bills at." Complicating matters, if the hospital does its own facility coding and billing under APCs and the physician group uses a separate billing firm, "the two have the potential of not speaking frequently enough and creating risk."
And don't forget: The HHS Office of Inspector General can levy a civil money penalty of $10,000 per claim for every erroneous APC billed.
Various Charting Weaknesses Are Prevalent
HCFA demands a lot from physicians in terms of documentation. They can use either the 1995 or 1997 documentation guidelines for evaluation and management procedures. HCFA also proposed, but later rescinded, 1998 guidelines, which are now being revised and finalized with input from medical associations. Experts predict the new guidelines will be issued soon, but there will be a six-month breaking-in period, so they may not really take effect until 2001.
Here is a quick summary of documentation guidelines and areas within them that need improvement. Medicare rules say medical records must have three key elements included in the chart: patient history; exam; and medical decision-making. Each of these elements contains a host of specific demands.
(1) Patient History: When documenting a patient's history, physicians must describe:
-- Chief Complaint. All charts must have a chief complaint listed, regardless of the level of service provided.
-- History of Present Illness. For example, if an emergency department patient presents with a chief complaint of chest pain, the physician must document at least four of the following areas in order to bill Medicare for the two highest evaluation and management codes (according to the 1995 and 1997 documentation guidelines): Duration (i.e., one week); Severity (i.e., scale of one to 10); Quality (i.e., sharp, crushing); Context (i.e., pain came on while playing golf); Modifying Factors (i.e., pain got worse when I walked up stairs and better when I sat down); Associated Signs and Symptoms (i.e., nausea); and Timing (i.e., intermittent).
-- Past Family and Social History. For example, emergency physicians must document at least one fact from two of these three types of history for the higher evaluation and management code choice: Past history includes facts related to prior hypertension or diabetes, heart disease, cancer or past surgical procedures; Family history would focus on heart attacks, strokes, diabetes or other conditions found in siblings, parents or grandparents; Social history would cover where patients live and their smoking and drug or alcohol use.
-- Review of Symptoms. Physicians need to document more than 10 of the 14 systems listed by the Medicare guidelines to obtain the highest evaluation and management level. To bill for E/M levels two and three under the 1997 E/M documentation guidelines, you must document two organ systems; for level four, you must document two to nine systems; and to bill for a level five you must document over 10 systems. According to the 1995 and 1997 Medicare documentation guidelines, if the physician writes down "all other systems reviewed and negative," they don't need to list as many systems and are still allowed to bill the more comprehensive evaluation and management service levels, Stimler says.
Where in the documentation albatross for the patient's history do physicians have problems? For the most part, physicians simply don't write down the details Medicare requires, Stimler says. This is especially true when they must use handwritten charts (as opposed to dictated, templated or electronic charting systems). "I can elicit a full history in 1-1/2 to 2 minutes, but writing it all down takes much longer." If the required material for the history is not listed on the chart or if the handwriting is incomprehensible, all coders, including those employed by the hospital for APCs, will have a really hard time picking an appropriate level of either the CPT or APC code that's needed to submit a claim for physician or hospital services.
Also, many coders lack medical expertise, so they rely on finding specific phrases, such as ROS (for review of systems), HPI (for history of present illness), and PFSH (for past family and social history) - along with the required elements for each - in order to choose the level of service to bill for. Coders must be able to distinguish the various components for the services documented by the physicians. Physicians who ramble on in paragraph form make it very tough for coders to check if the required components are in the chart. For example, under patient history, the physician may combine in paragraph form the history of present illness with the review of systems, thus creating a nightmare for the coder trying to separate these components and figure out what level of service to bill.
"Coders look at this big blob of a paragraph and have trouble counting the number of systems or elements under the history of present illness because they are lumped together with the review of systems," Stimler says. The physician should clearly separate these components by writing, for example: "37-year-old female with a chief complaint of chest pain. HPI: Quality: sharp. Duration: three months. Timing: increasing."
(2) Exam: Physicians must start preparing to document their patient exams according to bodily systems, not areas. Although the 1995 Medicare documentation guidelines allow physicians to document by areas of the body, there has been a clear shift to system exam documentation since 1997, Stimler says. The 1997 guidelines direct physicians to document 18 different elements for the highest-level evaluation and management code choice and cover two items under nine systems. The newly proposed guidelines probably will call for 18 total elements in five or more systems (e.g., in the cardiovascular system, there are four elements, such as listening to the heart for murmurs or rubs and palpation of the heart for heaves on the chest wall). "Physicians have to separate these elements so the coder can say, 'OK, here are two elements under this system.' You can't run them all together and expect the coders to count the number of elements required."
(3) Medical Decision-Making: After a physician takes the patient history and performs an exam, a list of differential diagnoses is created in his or her mind. From this list, which should be documented, the physician orders ancillary tests and specific treatment modalities, including procedures. "Physicians should use differential diagnoses since it helps in the face of an audit to show an auditor what you were thinking prior to ordering studies and treatments. It is a good measure of what type of medical decision-making went into the care of the patient," Stimler says. Medical decision-making also includes old-record review and conversations with families and medical consultants. Also incorporate into the chart reports on studies from physicians, such as radiologists, or an emergency physician's interpretation of X-rays and EKGs as well as orders and interpretations of lab values.
Having these elements plainly visible to coders enhances the ability of physicians and hospitals to code at accurate CPT evaluation and management levels, and proper facility fee and eventually APC levels for hospitals. "All these areas come into play in creating a more comprehensive medical record. They show the true work physicians have provided to the patient."
Hospitals, Physicians Must Join Forces
Stimler says hospitals have to make it their business to improve physician documentation ASAP. His tips:
(1) Make sure your physician group is trained in the newest documentation techniques. Consider subsidizing the cost of training MDs in documentation nuances.
(2) Either provide dictation services to physicians who provide hospital outpatient services or pay for an outsourced transcription firm to accomplish the goal of readable charts. These finished charts must have each of the elements in a form that's meaningful to hospital and physician coding professionals. "If you outsource your transcription, choose a vendor who has high accuracy and a short turn-around time, and has developed helpful templates that the physicians can use to separate all the important components of the patient history, exam and medical decision-making. Just dictating paragraphs that still run together will not really help that much because it retards the ability of the coders to quickly choose the proper code. Written charts are not going to cut it much longer anyway."
(3) Consider using commercially developed charting templates - but for lower-level evaluation and management services. Dictated charts are better for higher and more comprehensive encounters and admitted, transferred or critical care cases. A dictated chart costs about $6, while a commercially templated chart costs about $1.50 to $2.50. Either one or a mixture provides a good return on investment since an average emergency room visit is billed at $350.
(4) Consider working with physician groups to explore proprietary software that electronically creates charts - and each product's pros and cons. Only the hospital administrative staff and nursing leadership in concert with physicians can determine what product fulfills their needs.
(5) Develop compliance programs that deal with documentation expectations, training techniques and plans, criteria for code choices and effective billing techniques. Look at the OIG compliance-program guidance for third-party billers. The OIG also is slated to release compliance-program guidance for physicians this spring.