Is your documentation as accurate as possible?

Is your documentation as accurate as possible?

In the ICD-10 era, doctors can't afford to be vague

October 2016

Published in the October 2016 issue of Today’s Hospitalist

IT’S OCTOBER, which means that coding departments everywhere have several thousand new ICD-10 codes to deal with. That’s on top of the tens of thousands that took effect last fall.

While hospitalists are probably fielding fewer queries from coders related to ICD-10 now than they were a year ago, that doesn’t mean their documentation can’t improve. Making that happen is one of the goals of Aziz A. Ansari, DO, associate division director of hospital medicine at Loyola University Medical Center in Maywood, Ill.

A lead physician advisor for clinical documentation improvement at Loyola, Dr. Ansari has been speaking at medical conferences and hospitalist programs around the country, teaching doctors how to make their documentation much more specific in the ICD-10 era.

“The stakes related to physician documentation are now much higher.”

~ Aziz A. Ansari, DO
Loyola University Medical Center

Dr. Ansari makes it clear that better documentation is not about learning ICD-10 codes. “Personally, I get frightened when I see ICD-10 codes,” he says. “Hospitalists have coders who can comb through our notes and, based on precise documentation, find the best ICD-10 codes to use.”

But he’s quick to add that physician documentation helps determine a patient’s severity of illness and risk of mortality. Those factors are key to both making the right DRG assignment and getting the appropriate reimbursement.

And because ICD-10 features much more precise codes, “it’s going to be much easier to measure both hospitals’ and individual physicians’ quality scores, including mortality rates,” says Dr. Ansari. “The stakes related to physician documentation are now much higher.”

The impact on quality scores
Given the precision of ICD-10 codes, researchers plan to use them to report diseases and research the effects of different treatments. ICD-10 will also allow for better tracking of the types of patients clinicians treat and lead to more appropriate reimbursement.

But Dr. Ansari is interested in how ICD-10 relates to documentation and its role in quality reporting, both for physicians and hospitals. To illustrate how documentation can affect both personal and hospital metrics, he gives the example of patient safety indicators (PSIs) and hospital-acquired conditions (HACs).

“Documenting an event as ‘present on admission’ removes it as a preventable, hospital-related PSI or HAC,” he says. If doctors don’t document “present on admission” for stage III and IV pressure ulcers or manifestations of poor glycemic control, both the individual physician’s and hospital’s PSI quality score will go down.

As Dr. Ansari explains, documentation drives many other factors besides PSIs. One significant measure is severity of illness/risk of mortality (SOI/ROM). “This is a complicated risk stratification score that depends on our documentation,” he says, “specifically on our primary diagnosis and associated secondary diagnoses.”

SOI/ROM is rated on a scale of 1 (minor) to 4 (extreme). When clinicians don’t provide precise documentation to show how sick their complex patients really are, those doctors’ observed-to-expected mortality—a ratio determined by SOI/ROM—may be inappropriately high. That would not have been the case with more thorough documentation.

On the other hand, “when a sick patient with a high SOI/ROM is discharged alive,” says Dr. Ansari, “both the hospital’s and the physician’s observed-to-expected mortality profile improve.”

Besides SOI/ROM scores, documentation affects the DRG, which in turn determines a host of other metrics and factors, such as Medicare’s geometric mean length of stay (GMLOS) and the hospital’s case mix index. All those factors—and many more—work together to determine reimbursement.

What’s important, Dr. Ansari says, is that accurate documentation enables hospitals to receive what they are appropriately due for treating complex patients. “Documentation shortfalls,” he points out, “affect everyone’s bottom line, including that of your hospitalist group.”

Secondary diagnoses
According to Dr. Ansari, one documentation feature that has a huge impact on both the assigned DRG and SOI/ ROM scores is secondary diagnoses. These need to be very specifically documented, he says, as well as carried through to the discharge summary to avoid potential audits.

Why? Because documenting secondary diagnoses is how you capture patients’ comorbid conditions (CCs) and major comorbid conditions (MCCs). “It is those,” he notes, “that move a diagnosis to a higher-weighted DRG.”

He offers this example that shows the impact of appropriately documenting secondary diagnoses. Here are both non-specific and specific documentation examples for a patient with heart failure linked to chronic kidney disease and hypertension:


Words to avoid
To further improve documentation, Dr. Ansari also singles out words and phrases that physicians should stop using. First on that list is “longstanding.” Instead, he says, indicate acuity—”acute on chronic”—even if it’s obvious.

He also recommends steering clear of “history of” because that implies that the condition has resolved. “You shouldn’t, for instance, document ‘history of stage IV breast cancer,’ ” he says. Instead, it should be, “Primary breast cancer with metastases to the brain” or “Stage IV breast cancer with metastases to the brain.”

At the same time, Dr. Ansari thinks that doctors should definitely make use of several adjectives, particularly when documenting a primary or secondary diagnosis they may not be sure of. It is perfectly OK, for instance, to use the following: “possible,” “probable,” “likely” and “suspected.”

Something else doctors should document: cause and effect, spelling out why something may have occurred. “The phrases I use are ‘due to’ or ‘secondary to,’ as in ‘acute diastolic heart failure secondary to uncontrolled HTN,’ ” he says. And when listing differentials, he adds, make sure to zero in on a diagnosis before discharge.

Putting it all together
How do all these principles work together? In the following example is a note that Dr. Ansari actually wrote in the right hand column. To the left is much more vague documentation of the same conditions.

“This is an example of both precise and poor documentation in the care of a complex patient,” he says.


The easiest explanation that Dr. Ansari is able to give for how to make your documentation as precise as possible is this: “Just be a thorough physician,” he says.

“What we’re doing is documenting how we think, and presenting a very clear picture of the patients whom we know on a very detailed level, putting our thought processes on paper.”

Doctors should know, for instance, whether a patient has diastolic or systolic heart failure vs. “CHF,” or if a patient has AKI vs. “elevated creatinine.”

“These are the kinds of details that we need to document,” he says.
Does it take more time to detail all the particulars of what you’re thinking? “That depends on your level of tolerance and frustration,” he says. However, he points out that the consequences of not spending that time are steep, while documenting specifics can become a good habit that improves the overall quality of care delivered to patients.

Phyllis Maguire is Executive Editor of Today’s Hospitalist.