Washington & West Resources

Written by Cynthia M. Lipsitz, MD, MPH

Best Practice Physician Documentation Tips To Prevent Length Of Stay Denials

The last few days of an acute inpatient stay are prime targets for auditors. Time and again, these days are denied because the “the documentation provided does not support the need for the patient to continue to receive services at the acute inpatient level of care.”

These denials can be overturned with time and the right expertise. The goal, however, is to prevent the denial in the first place. The length of stay does not have to become a loss with appropriate clinical documentation.

Auditors, with their checklists of discharge criteria, are looking for documented evidence of the severity of the patient’s illness (SOI) and the intensity of services (IOS) that the patient requires. (Auditors often begin and end their review with the physician documentation.) If auditors can’t identify this information, written legibly and in terms they can understand, they are likely to determine that the patient “could have received further treatment at a lower level of care.” As a result, the last few days of care are denied.

As most of us know, a key part of preventing denials lies in the hand of our physician’s documentation. But, asking busy physicians to just “document better” or worse yet, face penalties for “poor documentation” is likely to bring on a chorus of “Well, tell me what you want me to write!!”

As a physician who’s appealed hundreds of these denials, and who has also written hundreds of progress notes, I’m convinced that many LOS (length of stay) denials can be prevented.

What if there were some simple rules for LOS notes?

Consider this scenario adapted from actual cases referred to us:

Mrs. Gray, a 65 year old obese diabetic former smoker, had a total knee replacement. She has a postoperative fever and doesn’t feel well. Her orthopedist writes this plan: “Observe over weekend.”

But why does she require observation? Does this plan mean that she needs the Observation level of care? How sick is she? What services does she require? In other words, writing “Observe over weekend” does nothing to support the physician’s reasons for this plan.

What if the physician had written this best practice progress note?

“Assessment and Plan: Postoperative fever: possible sources of fever include wound infection, sepsis, urinary tract infection, or pneumonia. Get chest x-ray, blood cultures x 2, urine culture. Will consult Infectious Diseases for advice on further management. Reassess the patient in 24 hours and consider wound culture. Increase IV fluid rate to 125cc/hr.”

This note incorporates a few simple rules that physicians can follow to improve the documentation of their patient care which will result in fewer denials:

1. Write not only for other physicians, but also for utilization reviewers, coders, and auditors. The days of using the medical record to communicate only with other caregivers are over.
2. Document SOI (severity of illness) and IOS (intensity of services): what makes your patient so sick that she has to remain hospitalized? What services can only be given at this level of care?
3. Treat weekend days just like any others. Reassess patients for potential discharge on an ongoing, daily basis.
4. State why your plan is appropriate – remember the key word BECAUSE, even if you don’t specifically write it. “The patient needs acute inpatient care because the source of her fever is unclear and needs further evaluation with multiple studies and consultations.”
5. Include detailed data to support your decision. Medical decision-making is complex, so write down all the facts that go into your plan.
6. Avoid copying-and-pasting boilerplate statements. Repeatedly using the same justification for continued LOS weakens your arguments.
7. Begin discharge planning as soon as possible.

These simple rules can help you keep your LOS from becoming a LOSS.

Cynthia Lipsitz, M.D.

November 15, 2010

About the Author

Cynthia M. Lipsitz, MD, MPH, is a Senior Medical Reviewer with Washington and West, LLC, an appeals and denials management company.  In this capacity she maintains familiarity with current standards of medical care, Medicare and private payer hospitalization criteria and coverage policies.

Contact the Author: c.lipsitz@washingtonwest.com

Written by Cynthia M. Lipsitz, MD, MPH

As government auditors expand their lists of audit issues, medical records departments are working diligently to get healthcare professionals to improve their documentation.

And with good reason:  Significant financial risks can be traced back to poorly documented notes and orders.  Poor documentation increases the likelihood of miscoding, inaccurate DRG assignments and audit denials.  Patterns of these irregularities can lead to charges of fraud and abuse, plus further scrutiny from investigators.

Solutions to the documentation problem are not easy to find, and all come with both pros and cons. Paper or electronic templates offer some advantages, but it’s all too easy to leave great portions of them blank. Another option is to cut and paste sections of electronic notes, and wind up with the same documentation day after day. This practice, however, increases the risk of repeated inaccuracies and miscommunication. Standard-order sets offer the advantage of guidance based on medical evidence, but their decision algorithms can be frustrating and difficult to follow.

Documentation specialists and coders have their own set of headaches in this area. Identifying the ideal physician query, one that is timely, succinct, and actually gets a response, is the subject of many a conference, webinar or newsletter.  It’s often tough to design a question that is clear and specific but doesn’t suggest a response.

The longer I work in the field of denials management, medical coding and documentation improvement, the more I doubt that the holy grail of clinical documentation ever will be found. But I do think that there are some simple reminders that can help clinicians  improve their documentation skills. Here’s the latest.

Think like a professor, write like a medical student. If we were to combine the thought processes and communication skills that we’ve acquired in our clinical experience with some of the lessons we learned as students, I believe our documentation would improve.

Think Like a Professor

Remember teaching rounds? Skilled professors or attending physicians would guide their students through the thought processes necessary to formulate a differential diagnosis and explain the rationale for decisions and plans. The best teachers had

• An extensive reserve of knowledge
• The experience to anticipate the sequence of events that a workup should follow
• Excellent reasoning to justify their actions; and
• Crystal-clear communication skills that make them easy to understand.

These are precisely the elements that are needed in physician documentation. If only the physician would write down what he thinks is happening with his or her patient, how severely ill they are, what direction he wants his workup to follow, his patient’s anticipated service needs, and why his plans are necessary. Then, the reader of the medical record – be it medical student, colleague, coder or auditor – would be more likely to understand and use the documented information appropriately, according to their individual needs.

Too often, though, the serious consideration that a patient’s care is given simply is not documented.  The quality of care may be outstanding, but the hospital and physician won’t get paid for it. Auditors will claim that “there is no documentation to support the medical necessity of this patient’s admission and continued hospital stay,” and deny the claim.

Write Like a Medical Student

In general, medical students are taught to write progress notes that include at a minimum:

• Patient’s name and date of birth on each page
• Date and time
• Subjective statement – usually what the patient actually states
• Objective statement – vital signs, physical exam with pertinent positive and negative findings, labs, imaging, procedure results and basically anything else that has been objectively determined
• Assessment – number each problem and discuss it: is it stable, improving, worsening? Ideas about its cause? Are other problems complicating it? Have there been any other complications? What has the workup to date told you, and what more might be needed?
• Plan – more testing? More intense services? Does the rest of the workup depend on any pending test results? And why is it necessary to do these things? Justify your decisions.
• Signature (legible, of course), printed name and identification number

During internship, residency and fellowships, we learn more specific documentation standards as determined by our specialty. Thus, surgeons learn procedure and operative notes, OB-GYNs learn delivery notes, pediatricians learn NICU notes, etc. But the fundamental lesson is to document thoroughly, accurately and clearly.

Putting the Two Together

It IS possible for healthcare professionals to write better notes, not only to improve quality of care but also to ensure that they and their hospitals get paid for their work. It is critically important to document daily the severity of the patient’s illness and why they require a particular intensity of services. Medical records need to clearly reflect the provider’s thought processes and justify the patient’s need for services at a specific level of care.

Healthcare providers must strive to write down their professorial thoughts in a thorough (but not necessarily lengthy) student -style format.

About the Author

Cynthia M. Lipsitz, MD, MPH, is a Senior Medical Reviewer with Washington and West, LLC, an appeals and denials management company.  In this capacity she maintains familiarity with current standards of medical care, Medicare and private payer hospitalization criteria and coverage policies.

Contact the Author:  c.lipsitz@washingtonwest.com

Written by Cynthia M. Lipsitz, MD, MPH

As the senior medical reviewer for Washington and West, a denials management company, I’ve seen documentation errors and omissions that clearly put hospitals and physicians at risk for denials. What’s more, as I review medical records from across the country, I’m starting to see patterns of errors at individual hospitals and by individual physicians . And, if I’m seeing patterns as one lone reviewer, you can just imagine what government auditors are finding.

I strongly feel that most physicians don’t understand the link between what they write in a medical record and what the hospital, and they, get paid. Nor do they understand the very real risks of fraud and abuse charges that can result from patterns of errors.

Understandably, health care providers put patient care first, and we wouldn’t want things any other way. When I’m called to see a patient with chest pain, writing a detailed note is just not the first thing on my priority list. Too often, though, providing excellent patient care is used as an excuse for very poor documentation.

Some physicians feel that writing good notes isn’t their concern – that they have PA’s, NP’s or residents to do the work. Some don’t see the link between quality care and documentation, and think that as long as their patients do well, that’s all that really matters. Of course everyone is stressed for time, and so notes are dashed off all too quickly. And some physicians honestly don’t have the information they need to do a better job of documenting.

The fact is, we physicians haven’t been taught very much about documentation in medical school or training. We usually get a general introduction to writing histories and physicals, and to the problem-oriented medical record. We get some legal tips on documentation practices aimed at reducing professional liability risks. But when it comes to writing detailed notes that justify our medical care decisions, well, that medical school class never happened.

Here are some examples of the documentation errors I’ve seen that translate to denials and dollars:

1. Tops on my list is the lack of justification. I want to say “Tell me, Doc, why does this patient need inpatient care instead of observation? Why does the patient need to stay another day?” Physicians need to remember to use the word “because,” as in “The patient needs to stay another day because his hemoglobin has not stabilized and he continues to complain of dizziness.”

2. Too often problem lists are made, but no diagnoses are suggested, or else the principal diagnosis is not spelled out clearly.

3. Physicians don’t fully explain the impact of co-morbid conditions and complications.

4. Handwritten notes are completely illegible, and times and dates are missing – and finally

5. Electronic medical records are cut-and-pasted without updating.

All of these poor practices can lead to erroneous coding, improper DRG calculations, and denials. What’s more, for those of us in denials management, these practices make it very difficult to write strong appeals.

So, what are hospitals to do? It’s critical that hospital compliance programs hit their marks, and physicians must be part of the process. Hospitals need to approach these issues from several directions by:

1. Regularly reviewing hospital and physician performance statistics

2. Providing physicians feedback with data on dollars lost and denials gained

3. Creating documentation aids, electronic or paper, that make it easy to do the right thing

4. Educating physicians in ways that are simple and direct, and

5. Establishing on-going, short, structured, small -group information exchanges between medical records staff and physicians with everybody leaving their egos at the door

The bottom line is, it takes a multipronged, customized, and creative program to ensure that everyone – including physicians – plays his part to comply with the rules and reduce the risks of denials.

About the Author

Cynthia M. Lipsitz, MD, MPH, is a Senior Medical Reviewer with Washington and West, LLC, an appeals and denials management company.  In this capacity she maintains familiarity with current standards of medical care, Medicare and private payer hospitalization criteria, and coverage policies.   Dr. Lipsitz has reviewed records and observed documentation patterns from a variety of hospitals across the country, and has a heightened understanding of issues that lead to denials.  With over 25 years of experience in ambulatory and hospital medicine, public health administration, and health promotion software development, she brings an understanding of the realities of medical practice and administration to the field of denials management.

Contact the Author:  c.lipsitz@washingtonwest.com

Written by Cynthia M. Lipsitz, MD, MPH

There’s a subject getting a lot of popular interest these days, called behavioral economics.

There have been some suggestions lately that this principle can be very useful in health care; in fact, an article in the Harvard Business Review in March of this year cited behavioral economics as one of the top 10 innovations that will transform medicine in the future.

In a nutshell, BE is based on the fact that we often don’t do what we should, like exercise or eat healthy foods, or, as physicians, document our diagnoses and decisions clearly. But we can be nudged (also the name of a book on the subject) or gently guided into doing the right thing if it’s not too hard to do or it can be made a part of a routine. In other words, we can arrange things so that the easy choice is also the right one.

Using the principles of BE may be one of the ways to encourage improvements in physician documentation, and this is likely to help us reverse denials or even prevent them. As a result there’ll be not only improved patient care, but also an improved bottom line. Very often as a medical reviewer with Washington and West, I see denials that could have been prevented or more easily argued if there had just been better documentation.

So, here are some examples of BE in use in the health care setting:

1. The Harvard radiology department noted overuse of certain costly xray studies that really weren’t in keeping with recommended quality care. So they came up with an automated questionnaire that helps the doctor think through the need for the test, or for another one. As a result, the rate of ordering the test was decreased, even as the volume of patients increased.

2. In another example, at Dartmouth-Hitchcock Medical Center, standardized orders were created for cases of pneumonia that developed out in the community. These orders follow well-thought-out consensus guidelines by expert groups, like the Infectious Diseases Society of America and the American Thoracic Society, and they were also met Joint Commission and CMS quality performance guidelines. The ordering physician checked off the orders that they felt applied to their patient. They found that this improved compliance with guidelines and decreased lengths of stay and patient deaths. In other words, they made it easy to do things right.

3. At WW, we found that at one hospital there was a clear link between denials and the attending physician on the case. We didn’t do a formal study, but we did find that feeding this information back to docs and administrators in a de-identified manner, especially info on the dollars lost, really opened their eyes to what’s at stake when a case is denied. We suspect that most doctors aren’t aware of the impact of their insufficient practices on the bottom line. when for example they write a diagnosis of heart failure vs. acute systolic on chronic diastolic heart failure in terms of DRG determinations.

Considering how complex medicine is these days, and how much there is to consider when making patient care decisions, I’m definitely in favor of any help I can get to make the right choices. But it’s critical to acknowledge that each patient is different, and that in the final analysis the patient’s doctor is really the person who knows that patient best. So, it’s critical to assure doctors that they are not being required to practice “cookbook medicine,” that is, to be forced to follow a set of general steps that might not fit their patient’s needs.

To me this means that any guidelines or standard order sets must allow for alternative options that a doctor can choose. AND there must also be required documentation of why that alternative choice was right for the patient– as I wrote about previously in the RAC Monitor, the most important word in medical documentation is “because.” If we can’t document why we made a decision, it’s as if we made no decision at all.

Finally I just want to say that, more and more, funds are being tied to doing things smarter – making better choices of tests, better use of antibiotics, etc and not to doing more things as in the past. Not only that, but now there’s increased scrutiny for fraud and abuse. If a hospital can adopt practices or technology that will make doing the right thing easier, we think that they’re likely to see fewer denials.

About the Author

Cynthia M. Lipsitz, MD, MPH, is a Senior Medical Reviewer with Washington and West, LLC, an appeals and denials management company.  In this capacity she maintains familiarity with current standards of medical care, Medicare and private payer hospitalization criteria, and coverage policies.   Dr. Lipsitz has reviewed records and observed documentation patterns from a variety of hospitals across the country, and has a heightened understanding of issues that lead to denials.  With over 25 years of experience in ambulatory and hospital medicine, public health administration, and health promotion software development, she brings an understanding of the realities of medical practice and administration to the field of denials management.

Contact the Author:  c.lipsitz@washingtonwest.com

Written by Cynthia M. Lipsitz, MD, MPH

As a physician reviewer for Washington & West, a denials and appeal management firm, my job is to examine medical records closely for documentation that will help me write a strong appeal letter. In so doing, I have the opportunity to see medical records from many different hospitals across the country.

Specifically, I am looking for the documentation that supports the need for admission to acute inpatient care and the need for this level of service throughout the length of stay. But more and more I’m finding problems that are unique to electronic documentation, and it appears that some of these problems may have caused the denial in the first place.

Certainly, a poor EHR makes recovery a whole lot harder for our hospital clients.

Here are some examples of problems I see with EMR:

1.    Information entered under “history of present illness” often merely is cut and pasted into the “course in hospital” for the discharge summary.

2.   Clinical staff appears to over utilize the cut-and-paste function, which is not convincing documentation of the patient‘s condition and often leads to erroneous and conflicting information.

3.   Numerous pages of records contain needless detail, thereby obscuring meaningful information that could support medical necessity.

4.   Design of the EHR often does not provide an understanding of the continuity of care from day to day. or the reasons why continuing care is necessary.

The migration to full health information management systems is a fact of life, and I support it. But it’s a double-edged sword that can work for – or against – a hospital that wishes to prevent denials for lack of medical necessity or insufficient documentation to support the level of care. After all, a Medicare or Medicaid audit reviewer, or a commercial payer reviewer, is not going to spend hours going through pages of information to try to figure out the justification for the admission. I suspect that payer auditors spend a limited amount of time reviewing a medical record, so if the needed information is not found easily, a denial will result.

Nevertheless, the pros of electronic medical records are significant:

· Notes, orders, etc. are legible.

· Providers can write notes rapidly and in a standardized fashion.

· Several departments can have simultaneous access to records.

· Reminders can guide decision-making and improve patient safety.

But the cons are also considerable:

· If notes are “cut and pasted” from one day to the next, and not updated or proofread carefully, they can contain conflicting information.

· Sifting through volumes of standardized notes is numbing. Important new information, such as a problem that requires acute evaluation, does not stand out.

· A lot of data in boxes is not helpful to prevent a denial or to support an appeal. However, a clearly written assessment of the patient’s problems and a justification for specific plans is extremely valuable, if seldom seen in an EHR. We want to show that the provider made a decision to keep the patient hospitalized and that the physician clearly documented the reason for that decision.

So, what can be done? First, having an up-to-date and flexible information systems department and a savvy chief information officer in place will be key to the unprecedented evolution of hospital information systems being driven by new federal regulations requiring “meaningful use” of EHR’s. These departments should:

· look for certified EHRs that are efficient, adaptable and user-friendly, not only for data entry but also for data retrieval and analysis

· encourage nurse and physician use of free text options to avoid meaningless, repetitive boiler-plate information

· develop an on-site interdisciplinary team to teach how to use the system and respond 24/7 to user needs

· allow appropriate online access to medical records by HIPAA-compliant business partners that perform denial management functions

· Emphasize to professional staff that they play a key role in ensuring that claims will be paid by clearly documenting and justifying their patient care decisions.

It comes down to this: electronic or not, a medical record is only as useful as the information it contains and its ability to communicate that information efficiently. Meaningful quality of a record’s information, and not quantity, will lead to better patient care and denial prevention.

About the Author

Cynthia M. Lipsitz, MD, MPH is a senior medical reviewer with Washington & West, LLC, an appeals and denials management company. In this capacity she maintains familiarity with current standards of medical care, Medicare and private-payer hospitalization criteria, and coverage policies. Dr. Lipsitz has reviewed records and observed documentation patterns from a variety of hospitals across the country, and has a heightened understanding of issues that lead to denials. With more than 25 years of experience in ambulatory and hospital medicine, public health administration, and health promotion software development, she brings an understanding of the realities of medical practice and administration to the field of denials management.

Contact the Author: c.lipsitz@washingtonwest.com