“Documentation is the beginning….not the end”

August 8th, 2014 / By Cheryl Manchenton, RN

I wish I could claim this quote as my own! I attended the AHIMA CDI Summit in Washington, D.C. this week and our keynote speaker was Laura Zubulake. My two takeaways from her presentation were the quote above and the affirmation that we should always do the right thing…not the easy thing.

One of the more interesting presentations of the week was from a cardiologist who provided insights into the CDI and HIM query process from his perspective. He had an excellent grasp of what was needed for accurate coding–until that one moment. I am sure many of us have been there: listening to a presentation, engaged and learning until we hear something that makes us cringe. He described the following scenario:

A patient was admitted with cholecystitis and underwent an elective laparoscopic cholecystectomy. Postoperatively, the patient’s heart rate, temperature and WBC count increased and his abdomen was distended with rebound tenderness. ID was consulted, antibiotics were started and the patient was discharged home six days later with no issues.

He asked us what was missing and, of course, postulated that the provider’s note was typical (I agree) and that the provider missed the opportunity to document sepsis and acute peritonitis, thereby justifying the extended length of stay and resources used. Without the proper documentation, the provider would be profiled as an outlier by a commercial payer for resource utilization and could be excluded from their network. In his hospital, the reimbursement would have been increased by approximately $22,000. Is there a problem here?

When I spoke that afternoon I asked the audience two polling questions:

  1. Who had heard the phrase: “It’s coding’s fault for ………”? 75% of the room raised their hand.
  2. Who had an issue with the cardiologist’s scenario above and the answer provided? Only three people raised their hand and only one of them knew why I was so distressed.

Sepsis developing after elective surgical procedures is considered an AHRQ Patient Safety Indicator (PSI 13) and part of the new PSI 90 composite score if it was not present on admission and if there is not an infectious diagnosis condition POA. So, the provider and the hospital’s reimbursement and utilization scores improved at the same time as the quality indicators for both the hospital and the provider suffered. A classic case of the Ripple Effect! In addition to clarifying the diagnosis of sepsis, his clarification needed to include: a) the POA status of sepsis (after careful review for clinical indicators) and b) the acuity of the cholecystitis. Sepsis as POA or acute cholecystitis would have excluded the case from PSI reporting, been a more accurate representation of the patient’s episode of care and might have provided an even better reimbursement.

HIM, CDI and Quality have to greatly increase their knowledge of quality metrics and methodology for accurate quality reflection and appropriate reimbursement along with development of hospital or system-wide processes. Documentation is truly the beginning…not the end.

Cheryl Manchenton is a Senior Inpatient Consultant and Project Manager for 3M Health Information Systems.