The Inpatient-Only List & The Role Utilization Review Can Play

By Tiffany Ferguson, LMSW, CMAC, ACM

EDITOR’S NOTE:
While there have been attempts to phase out the IPO List, the reality is that it continues to be a significant factor in healthcare reimbursement. This article will delve into the complexities of the IPO List, its impact on revenue, and the importance of accurate coding and utilization review in ensuring proper billing.

The Inpatient-Only (IPO) List is comprised of services, primarily surgical, that are designated as requiring inpatient care due to the nature of the procedure, the patient’s underlying physical condition, or the need for extended post-operative recovery time.

This designation is critical, as Medicare and other payers reimburse and/or deny these procedures differently, depending on their recognition of the IPO List. Although it is clear where Medicare stands on the subject, it was not until April 2023, when the Centers for Medicare & Medicaid Services (CMS) released CMS 4201-F, commonly known as the “Medicare Advantage (MA) Final Rule,” that MA plans were also required to adhere to the IPO List.

However, this is not necessarily the case for commercial and managed Medicaid plans, which still have autonomy, per their provider guidelines and hospital contracts, to dictate their stance on the IPO List, unless state-mandated otherwise. Regardless of the payers, getting it wrong can be significant to a hospital’s bottom line, as payers will often deny in full an incorrect authorization, such as completing an inpatient-only procedure in an outpatient setting of the hospital and billing the claim under an outpatient designation. This is where utilization review (UR) can collaborate with clinical documentation integrity (CDI), coding, and the rest of the revenue cycle to ensure that the status is correct up front. 

Sometimes this is when fallouts occur because an accountability owner and hardwired process do not exist, as the surgical process passes through so many departments. Regardless of the owner, however, there are some clear steps that need to occur to ensure the successful capture of IPO procedures.

Utilization review should be participating in access management by reviewing scheduled surgeries 2-3 days prior and collaborating with the scheduling and authorization team to make sure that each IPO procedure receives not only a pre-scheduled inpatient-only order in the medical record but also that the payer authorization matches the appropriate level of care.

Understanding that plans change in the operating room, documentation should be reviewed either by UR and/or the CDI team to evaluate for any changes that may have adjusted an outpatient procedure to an inpatient, requiring an updated level-of-care order to be obtained.

Even though education is important, providers should also partner with surgeons’ offices to ensure that they are aware of their potential missed opportunities for accuracy with IPO procedures and the authorization process. It is also important to understand that the pre-authorization function is typically completed by medical assistants and/or surgery schedulers, thus consideration should be given to maximize technology and hardwire the process – such as by adding hard stops in the electronic medical record (EMR) for when a procedural code is entered for surgery, via an alert when the appropriate level of care opens, notifying the user that this is an IPO procedure.

Some hospitals are still using fax and paper to schedule procedures, so consider giving custom forms to your top surgeon offices that identify very clearly which surgeries they perform that appear on the IPO List to avoid confusion leading to denials.

Finally, review your denials data with your revenue cycle and billing team. Which IPO procedures were missed? Break down what happened in each case and determine what procedure it was, along with which group was performing the procedure. This will provide key details in payers practices and lead the team upstream to work out any missteps that occurred in the process.

Accurate coding, diligent utilization review, and a clear understanding of the IPO List are vital components of revenue cycle management for healthcare organizations. The financial implications of IPO procedures are significant, underscoring the importance of precise billing and adherence to regulatory requirements.

Staying informed about the ever-evolving healthcare landscape is crucial, as political and regulatory changes can impact reimbursement policies and ultimately affect a hospital’s bottom line.

Pediatric Physician Advisors – A Commonly Missed Key to Healthy Hospital Operations

By Juliet Ugarte Hopkins, MD

Just as the role of physician advisors has come to the forefront of the healthcare world over the last decade and a half, so too has the subset of pediatric physician advisors in recent years.

Their expanding ranks and critical developments nationwide affecting hospital pediatric units and availability of pediatric services now makes discussion about the importance and future of the role unavoidable.

Pediatric services have never been considered financially impactful. Without routine, profitable, diagnostic and preventative procedures like colonoscopies and cardiac catheterizations, as in the adult population, and the harsh truth that Medicaid and managed Medicaid plans notoriously pay pennies on the dollar for reimbursement of services, the overarching understanding has been that pediatric cost of care will essentially break even for health systems. However, as hospitals close their pediatric units and cut back on their outpatient services, it’s clear that getting paid less than expected for services provided is even worse than being paid what’s expected. 

While pediatric medicine is advancing year over year, our nation’s hospitals’ capability to provide this level of care is dwindling due to insufficient payment.

There is no side-by-side comparison with adult counterparts, when it comes to many aspects of patient care. From clinical presentation and clinical trials to treatment modalities and Food and Drug Administration- (FDA)-approved pharmaceuticals, there often are stark differences – or even a true lack of comparative data. One impactful example is the content of common clinical guideline criteria used by case/utilization managers and payers for statusing patients. While they may have pediatric-specific criteria, there often is nothing that even mentions major treatment pathways usually only seen in pediatrics. 

Additionally, it is very common for payer medical directors to misidentify the major factors of a case and try to fit complicated diagnoses into simplistic conditions. Hospitals that have pediatric departments need physician advisors with pediatric expertise. The issue is not simply having internal staff who can appropriately identify patients meeting criteria for inpatient status, but also having staff with the ability to explain the reasoning to a payer medical director who lacks this expertise. 

Top-hitting diagnoses in hospital pediatrics are not really all that different from the adult world, including sepsis, acute respiratory failure, and malnutrition. However, pediatric training and experience are required to ensure the subtleties of identification, stabilization, and treatment, as completely illustrated in the documentation, captured by the coders, and appreciated by the payers.

One of the key roles physician advisors play is to maintain the financial health of hospitals so they can maintain the physical health of the communities they serve. It’s high time health systems recognize the pediatric patients of these communities and the critical needs they require to grow up and develop into the educators, artists, change-makers, and even medical professionals we’ll all rely on and be inspired by for generations to come.

Is a Lack of Cultural Competency Closing Doors on Access to Care?

By Tiffany Ferguson, LMSW, CMAC, ACM

As it pertains to my students undergoing clinical training, one of the social workers who is currently working in an elementary school in a predominantly Hispanic community recently discussed a situation of concern regarding a student’s mother. Because the social worker is bilingual, and from this particular community, she is a trusted resource for many local families of children who attend the school.

Knowing my medical social work background, I think she intentionally mentioned this case to discuss for assistance. She described to me a story of a student’s mother who came to the school asking for help from the counselors. She is a primarily Spanish-speaking woman who has been diagnosed with Stage 3 ovarian cancer. She has been paying cash for her medical appointments, because her husband is approximately $1,000 per month over income for Medicaid; however, he works for a small company as a painter and does not have health insurance.

When discussing the Marketplace coverage, the woman said she believed that she would not be approved for coverage because of her cancer diagnosis. When I asked about the oncology office, the social worker stated that they worked out a cash price for the patient as a 50-percent discount; however, with the expectation of chemotherapy she cannot afford the treatment. 

I could go on about what occurred in this case and the missteps of this office in failing to support her by not assisting her in obtaining health insurance, much less the lack of willingness to help her apply for Social Security disability. I also could go on about the lack of cultural and empathic support from this office, as this woman must now face a difficult prognosis while trying to parent small children. 

I tell this story because ironically, this past week, Kaiser Family Foundation (KFF) news posted their report on Health and Health Care Experiences of Immigrants: The 2023 KFF/LA Times Survey of Immigrants | KFF. The narrative highlights a disappointing story in our healthcare system, wherein we fail to acknowledge and recognize cultural biases and their impact on health equity.

The survey of 3,300 participants found that 29 percent of respondents stated that it is hard to receive respectful and culturally competent care. The study also highlighted that because of the trend in employment with and/or running small businesses among immigrant families, the majority of the population is often over-income for Medicaid, but lacks access to health insurance, likely because of cost. Additionally, the study found a hesitancy of immigrants to seek healthcare services, regardless of citizenship, citing prevalence of immigration-related fears and language barriers being the primary reasons.

The study reviewed the relevant differences that exist among coverage for immigrants in states that have expanded Affordable Care Act (ACA) Medicaid coverage and those who do not. The report even goes into the disparities among this population in seeking assistance for housing, food, healthcare, or other social programs because of the concern and confusion around inconsistent eligibility requirements. 

In the recent publication on the CMS Framework for Health Equity 2022–2032, the Centers for Medicare & Medicaid Services (CMS) provides their top priorities to improve health equity in our country, with priority 3 and 4 most aligning for a recommended increase in culturally tailored services and greater workforce support to reduce disparities. Maybe the report was intended to be vague or high-level, but it missed the direct need to address implicit biases on healthcare delivery or mention a path for greater minority representation among healthcare providers.

As much as healthcare is striving to be the answer to all social complexities, it is relevant to note that my patient story was impacted by the local school counselor who was compassionate enough to try to find answers and connect this woman with the resources she needs.  

Initial Patient Assessment: Understanding CM Documentation

By Tiffany Ferguson, LMSW, CMAC, ACM

Following my recent talks about Z-code capture and the value of reviewing case management documentation, I thought I would spend some time today focusing on the ideal state of what case management documentation should look like.

I must also confess that recent social-media posts questioning the professional ownership of the initial assessment and whether this could be delegated to a supportive employee to collect information for the clinical staff also prompted me to write this article. Although my reason is multifaceted, the question often comes from a model of case management that is primarily task-driven for discharge needs, rather than a collaborative process of patient and care team engagement to ensure the patient’s needs are met for the progression and transition of care from the acute setting.

In this narrative, case management (CM) has appropriately screened their patients to identify who needs their services and who does not; this is done either by consult, independent screening, or technology algorithms in the electronic medical record (EMR) that help streamline the process. Thus, the role for CM intervention is clearly needed by the case management professional (such as an RN, social worker, or other aligned healthcare professional.)

Case management documentation should not be a simple to-do list of tasks yet to be completed, directed towards the patient discharge. And the initial assessment should not be a slight expansion of the patient demographic sheet. After a patient has been screened for needing case management services, the documentation should reflect a thorough assessment that the CM completed with the patient to expand upon the documentation already obtained from the medical team, particularly the attending’s history and physical (H&P) and any initial nursing documentation. This may be a great time to also review the outpatient services or prior hospitalization(s) to incorporate known information into the conversation and assessment with the patient.

The initial assessment with the patient is the most important and proactive piece for CMs in laying the foundation of the care progression and transition-of-care process. This is not the time to quickly check boxes and ask generic questions, but rather engage with the patient and/or their family or representatives about the situation that landed them in the hospital – and to build a trusting relationship for the next stages of care towards discharge. 

Without getting into a full outline of a great CM initial assessment, the main areas of focus should really include the pre-hospital home environment, supports the patient was utilizing, an understanding of the patient’s prior functioning level, incorporation of key decision-makers in the patient’s plan of care, incorporation of the patient’s social determinants of health (SDoH) risk factors, and a determination if any of these factors may be impacting the patient’s access to or needs in managing their medical care. Additionally, the initial assessment should discuss the anticipated care plan for transition and any potential steps and/or barriers that may impede them. 

The ongoing notes, and particularly the last note the CM writes when they are confirming the final plan for patient discharge, should be the end to the story, after the progression updates throughout the patient stay. This note does not have to happen necessarily when the patient leaves the hospital, it could be done prior, once the obligations of the CM’s role in the transition plan are met.

The documentation should clearly reflect that the CM met the requirements for the Conditions of Participation Discharge Planning (§482.43 CoP: Discharge Planning), such as patient choice and integration of patient and/or family in the care planning process. The patient disposition should be identified and specific to if the patient was just returning to their custodial nursing home or if they were going to obtain skilled nursing care upon their return. The documentation should clearly identify if the patient is resuming pre-existing home health services, or if this is something new that is being arranged because of the patient’s hospitalization. Additionally, the expedited start date of services should be identified for any post-acute arrangements in the patient’s documentation.

The fulfillment of these obligations may absolutely incorporate the advancements of the EMR, with use of drop-downs and shared fields across note types and authors for collaboration. However, it should also hold to two principles: If it was not documented, it was not done, and the documentation should concisely depict the needed information for the intended audience. 

The Inpatient Only List

By Marie Stinebuck, MBA, MSN, ACM

Several years ago, the Centers for Medicare and Medicaid (CMS) announced the decision to end the Inpatient Only list (IPO), but as we all know, that decision did not last long. In 2021, more than 500 procedures were removed from the Inpatient Only list to move toward the extinction of the list for good. In 2022, CMS put most of those procedures back on the IPO list with the decision to devise a more calculated assessment for how procedures will be removed with the consideration for patient safety and risk. It is unclear, with how political landscapes change, if the IPO list will once again be on the chopping block. Payment of an IPO procedure within the hospital setting is significantly higher than downgrading that procedure to an outpatient payment.

The capture and accurate billing of these IPO procedures is vital to the hospitals that perform the procedures. The front-end capture and verification of accurate codes, involvement, and communication with the utilization review (UR) team are crucial. Specifically, there is a vital role for utilization review to incorporate pre- and post-review processes to ensure capture of the Inpatient Only procedures to ensure accurate billing of the procedures.

Points to know related to the IPO list: 

• The definition of “Inpatient Only” services is generally, but not always, surgical services that require inpatient care because of the nature of the procedure, underlying physical condition of the individual requiring the service, or the need for at least 24 hours of post-operative recovery time or monitoring before safely discharging.

• When reviewing procedures for Inpatient Only procedures, words within the procedure to qualify for an inpatient procedure may include: revision, repair, or open.

• The IPO list comes out on the OPPS list each year at the end of the year, and goes into effect on January 1st. The IPO list outlines those procedures that Medicare will pay as an inpatient procedure in the acute hospital setting.

• Procedures are listed by the Hospital Common Procedure Coding System (HCPCS) code and include a short descriptor.

• Be aware of your top 5-10 contracts. Do they follow the IPO list? Which plans require a pre-authorization?

Changes for Medicare Advantage Plans:

In the final ruling on April 5th, CMS released CMS 4201-F, stating the Medicare Advantage plans will be required to follow the two-midnight rule and that will include also following the Inpatient Only list. CMS also stated that the Medicare Advantage plans can use commercial criteria such as MCG or InterQual as tools to assist in determining medical necessity, but must be transparent about their internal coverage criteria.

Utilization Review and IPO Procedures:

Best practice for UR pre-procedure is a review of all surgical cases for inclusion on the IPO list to ensure accurate capture of the procedure. Review of cases 2-3 days in advance is ideal to ensure time to follow up with the physician offices as needed for questions and adjustments to orders. A “day of” surgery review should also be completed to catch any last-minute add-ons to the surgery schedule. It is important to build relationships with the surgical scheduler at the surgeon’s office to discuss cases as needed and ensure smooth communication for cases that require additional review.

Observation services and surgical procedures:

When I work alongside UR nurses in hospitals across the country, and as many of you know from experience, many physicians are placing patients in a bed post-surgery in observation status without a diagnosis that requires observation monitoring. Scheduled surgeries must always begin with an Outpatient or Inpatient order. A patient should only receive additional observation services if an unexpected complication occurs that requires the patient to stay for monitoring. Observation is a service provided to outpatients with a physician order. The patient must meet observation criteria to bill for observation. If the physician’s reason for keeping the patient overnight is that it is late and the patient does not want to drive home, or the physician has always kept all his patients overnight, then the patient status should be captured in outpatient or extended recovery. The extended recovery status will also give your facility the data to reflect how often patients are staying overnight and utilizing a bed while your ED beds may be overflowing. Post-surgery, patients should be reviewed to ensure the procedure did not change, affecting the admission status. If the procedure has changed, payers requiring an authorization will likely require a new authorization for the procedure.

Hospital leadership and UR need to be aware that a hospital cannot bill for an Inpatient Only procedure that is performed as an outpatient procedure. It would be a rare occurrence in which you could bill inpatient without an inpatient order and would have to show the intent for inpatient admission. Ensure that you have a review process pre- and post-procedure to ensure these procedures are statused accurately. There is big money at stake here!

The Hospital Sepsis Program Core Elements 2023: A Blueprint for Sepsis Management

By Erica E. Remer, MD, CCDS

The Centers for Disease Control and Prevention (CDC) released the Hospital Sepsis Program Core Elements: 2023 to monitor and optimize hospital management and improve outcomes of sepsis. The Sepsis Core Elements (as it is referred to – I will abbreviate as SCE) are intended to “complement existing sepsis guidelines” and to help organizations develop additional guidelines for best-practice clinical care.

Sepsis is a leading cause of hospitalization and contributes to over a third of all hospital deaths. The SCE publication opens with the definition of sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection.” It reviews the evolution of clinical guidelines and notes that there has been great interest in developing clinical decision support tools to recognize and guide treatment of sepsis. The SCE notes that hospital sepsis quality improvement programs reduce hospital mortality, length of stay, and costs.

The SCE also lays out the process to develop a sepsis initiative. First, the individuals who will lead the program must be identified, and institutional leadership support must be procured. Having co-leaders be a physician and nurse is strongly recommended. Representatives from invested service lines should be gathered, such as infectious disease, critical care, emergency and hospital medicine, other primary services, nursing, pharmacy, and social work.

A needs analysis of the current state of the facility and the applicable regulatory and reporting requirements must be performed. Ambitious goals must be established based on the needs analysis. Sepsis must be a hospital priority, and staff buy-in must be effectuated.

Sufficient resources also must be allocated. This includes personnel, analytic support, and time. Sepsis activities must be integrated with other quality improvement and safety initiatives, like antimicrobial stewardship and Centers for Medicare & Medicaid Services (CMS) Severe Sepsis and Septic Shock: Management Bundle (SEP-1). Staff must be well-trained and held accountable. There must be collaboration across services, units, and the hospital system. Continual reassessment and updates of goals should be done at regular intervals.

The SCE spells out the steps and gives examples, but recommends that a formal structure for a quality improvement process be utilized. In the action step, they recommend implementation of a standardized screening process. This may be a paper-based or electronic tool, and may need to be done at recurring intervals if sepsis is initially not felt to be present. There are no clinically validated screening tools, but my strong advice is that regardless of what is used to trigger a second look (e.g., SIRS, SOFA, qSOFA), organ dysfunction needs to be present to diagnose sepsis.

Their next advice is to create and maintain a standardized care guideline in terms of clinical evaluation, treatment, and discharge planning. Hospital order sets can be designed and tailored to specific patient populations. Antibiotics should be administered promptly, followed by the next dose at the appropriate interval, continued for a reasonable duration, and discontinued when appropriate.

Development of a “code sepsis” protocol is also discussed. This harmonizes with a best-practice clinical care guideline and facilitates expedient treatment. The SCE also covers the common sequelae of sepsis and actions that can support recovery. Responsible care handoff is crucial to ensuring a patient has the best chance of returning to pre-sepsis or maximal function.

The section on tracking gives an overview of which metrics should be monitored and how to assess the success of the sepsis program. It may not be feasible to review every sepsis admission, but chart reviews of an adequate sample with root-cause analysis and process improvement consideration is recommended. Clinicians should receive feedback and education, informed by the chart reviews. Obviously, tracking must be combined with reporting.

It was noted that increased awareness of sepsis may lead to earlier recognition or inclusion of milder disease, which can lower perceived mortality from the disease. I will also add that including cases that only have SIRS without organ dysfunction (which many do not consider sepsis) will have the same effect.

The final step in the SCE is education. They do not limit it to healthcare providers, but include all patient-facing staff, trainees, patients, families, and caregivers. Patients who have had one episode of sepsis are at a higher risk for recurrent sepsis.

There are many resources offered in the SCE. The final offering is the Hospital Sepsis Program Core Elements Assessment Tool. It is a blueprint for hospitals to assess and optimize elements of sepsis care.

This publication is a welcome addition to the sepsis resources we have. Whether your institution uses “Sepsis-2” (which I strongly discourage) or has a pretty robust sepsis plan, I think the clinical leaders should read this document and review the guidelines. One-third of hospital deaths are due at least in part to sepsis – it’s time to do something about it.

CMS Releases New Source for Collecting Z Codes

By Tiffany Ferguson, LMSW, CMAC, ACM

To help improve the collection of the social determinants of health (SDoH) Z codes, the Centers for Medicare & Medicaid Services (CMS) Office of Minority Health last week released a new Z code infographic. 

The goal of this was to assist providers with understanding and using SDoH terminology in their documentation that will allow for greater alignment for ICD-10-CM Z code capture. As discussed, CMS believes that greater Z code capture will enhance quality improvement activities and provide further insights into the existing health inequities that hospitals and their community are facing. 

The infographic clarifies that Z codes can be captured and utilized in any health setting and by any provider as a tool for identifying the nine major categories that the Z codes represent, such as employment, housing, literacy, food insecurity, personal safety, and transportation. Reporting of Z codes would be for social factors that influence an individual’s health status, condition, or the reasons for receiving health services that are not classifiable elsewhere as diseases, injuries, or external causes. The infographic does clarify that SDoH information can be collected prior to, during, or after a health care encounter through structured assessments and/or screening tools.  However, the codes should only be assigned when the documentation specifies that the patient has an associated problem or risk factor that is influencing the patient’s health. Coding professionals can utilize documentation from social workers, community health workers, case managers, or nurses if the information is in the medical record. SDoH can also be self-reported if it is signed off by a licensed professional and in the medical record.

I would like to provide an example: Patient X has come into their primary care office visit for a “cough that won’t go away”. During the visit, patient X is provided paperwork to complete and sign as part of registration. When the medical assistant calls the patient back to the exam room, the patient discusses that they are unable to complete the paperwork because they have trouble with reading the material. 

The medical assistant is understanding and listens to the patient’s concerns related to their limited reading level and then proceeds to help patient X fill out the paperwork. Issues related to health literacy is documented in the patient’s record so the rest of the care team understands that this patient will be unable to read any materials that are printed at the end of their visit or during subsequent visits. At time of coding, the new code Z55.6, “problems related to health literacy,” are captured and reported.

CMS is continuing to offer outreach materials to increase the use of Z code capture and clearly has stressed that this is a valuable means for identifying, reporting, and analyzing how social determinants impact patients’ health.

How Can Case Management Provide Support for Coding?

By Tiffany Ferguson, LMSW, CMAC, ACM

Recently I talked about the greater integration needed between clinical documentation integrity (CDI) and utilization review (UR), and with the nudge of Laurie Johnson, today I thought I would discuss the benefits of coding and case management (CM) collaboration – in particular, the value of CM documentation. 

By no means is this going to be an article about how case management should be cross-trained to learn coding. However, I think there is value in coding being able to discuss with CM the role case management documentation plays in the coding process – and specifically, how clear documentation on patient dispositions and social determinants of health (SDoH) risk factors will help with record integrity. As I have talked about in previous articles and broadcasts, what better way for coding to clarify and capture Z-codes than from the descriptive documentation CM provides in their initial assessment and ongoing progress notes related to the involvement of patients, including SDoH risk factors of the hospitalization and their impact on the disposition plan?

The next most important information from CM is the post-acute care transfer (PACT) policy. The PACT policy by the Centers for Medicare & Medicaid Services (CMS) applies to specific Medicare Severity Diagnosis-Related Groups (MS-DRGs) rolled out in Table 5 of the annual releases for the Inpatient Prospective Payment System (IPPS) final rule to potentially adjust payment if the patient transferred to a post-acute care setting prior to the expected geometric mean length of stay (GMLOS) for each DRG. At a high level, if a patient is discharged or transferred to one of the specific post-acute settings and/or services prior to the GMLOS, the payment is adjusted to a per-diem rate that is calculated by dividing the MS-DRG rate by the GMLOS for those fewer days.

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has historically reviewed miscoding practices, and on several occasions, most recently in 2021, identified overpayments by hospitals that inappropriately reported post-acute locations and/or services.

This is where CM documentation is so important, because the final disposition of the patient not only impacts the required specificity for the coding team, but also the reimbursement for the patient’s hospitalization. The post-acute locations listed include (See the most recent MLN for specific details.):

• Acute transfers to psychiatric hospitals, cancer hospitals, or children’s hospitals;

• Inpatient rehab facilities;

• Long-term acute-care hospitals;

• Skilled nursing facilities;

• Home healthcare beginning within three days of discharge (not a resumption of services related to the hospitalization); and

• Home with hospice, at home or in a facility. 

So, for instance, if a patient is discharged to their existing nursing home, the CM may list “discharge home to facility X;” however, the coder will need to discern if that patient is just returning to their long-term care facility or whether they are expected to receive skilled nursing services at that facility. Another example is when the patient is discharged home with home health services, but the CM documentation does not specify the start date of those services. The hospital will miss reimbursement opportunities if the patient’s start date of services was greater than three days post-hospital discharge. Additionally, if the home health services were a resumption of care and not related to the inpatient hospitalization, the hospital could be unnecessarily giving up some of their financial reimbursement. 

CMs may not be aware of the value of their documentation, particularly for what is means of hospital reimbursement and record integrity. This is a great opportunity for coding to sit down with new and existing CMs to review their existing documentation and discuss the needs from the coding side to make sure the CMs are accurately documenting each patient’s social risk factors that are impacting the hospitalization – and the post-acute plan that is impacting the disposition codes for financial impact and record integrity.

Is Greater UR-CDI Integration On the Horizon?

By Tiffany Ferguson, LMSW, CMAC, ACM

There has been growing interest in the intersection of utilization review (UR) and clinical documentation integrity (CDI). With greater recent changes, such as more UR and CDI staff going remote and case management being left in the hospital, I can’t tell you how often Dr. Erica Remer and I are asked to speak about the partnership between CDI and UR – and together we have really learned a lot about how closely these two professions align. 

Recently, ACDIS responded to a public question about the potential for greater collaboration with utilization management, and even cross-training of team members. The question confirms the growing interest, but I must admit that the responses seemed to leave me wanting more. So here is the response I would give: absolutely, it is time for UR and CDI to look at further collaboration and intersection, and for a multitude of growing reasons. The top one is that they have long been specialists on the quest to both support clinical documentation and medical necessity for accurate revenue capture.

They also often collaborate with physician advisor(s) (PAs), which are often expected to cover both areas in their role, depending on hospital size. Greater alignment would benefit the PA as well.

From a physician standpoint, there is often confusion over the role both groups play, as they are often seen as people who bug physicians about their documentation. Greater coordination is needed in education and discussions with the physicians, which would eliminate multiple intrusions.

From a denial perspective, it can already be a pass-the-baton approach between UR and CDI as to what caused a denial: medical necessity or a DRG downgrade. The payers even sometimes use both reasons of clinical validation and medical necessity in their justification to deny, leaving the siloed CDI and UR specialist confused as who is expected to “write the letter.”

Technology is already working to integrate the two disciplines. Without mentioning names, the same techniques for UR and CDI are being configured and rolled out for efficiency across lines. The machine learning and algorithms being built to pull documentation or identify areas of opportunity from abnormal lab values have been proven to be of great benefit to the CDIS and the URS.

With greater movement of a remote workforce and the increasing requirements for the social determinants of health (SDoH) and health equity, case management (CM) is being pulled in a different direction. Although I know the importance of case management – to move the progression of care and understand resource over-utilization (utilization management) – the requirements CM specialists face are pushing them across the continuum and away from the traditional dyad and triad models.

Finally, these disciplines need each other. How often does the CDIS review a record and provide a primary diagnosis, maybe even a query, to the physician, only for it to be downgraded to observation services after a UR review process? Or how about the denial that comes through for a short-stay hospitalization – despite the clear and concise documentation by the physician, thanks to the great efforts of the CDIS and coder, the case does not present the relevant medical necessity to even pass the Two-Midnight Rule. Finally, how often does the UR team scour the record to find justification for a continued hospitalization to provide criteria and clinical documentation to the payer, when the CDIS has already completed a beautiful review that is sometimes not even visible to the URS in the record?

So, when the question is asked regarding greater collaboration between CDI and UR, the unequivocal answer is yes.

Programming note: Listen to live SDoH reports by Tiffany Ferguson, every Tuesday on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer.

Can AI Really Document a Patient Encounter?

By Erica E. Remer, MD, CCDS

I have accepted that it is inevitable that artificial intelligence, or AI, is going to become an integral part of our healthcare process. The question is how is it going to be used, and will it improve patient care? You know that I do not believe documentation is a burden. I believe it is part of the job and a responsibility.

Providers shouldn’t be documenting just to get it out of the way; they must recognize that it can enhance or detract from patient care.

I recently read an article in Medscape titled “We Asked Doctors Using AI Scribes: Just How Good Are They?” by Lorraine L. Janeczko, MPH. It points out that you need to get trained on the use of the hardware and the software, and it will likely take a while for you to feel comfortable to use it for all patients.

I wonder how the AI picks up on all the nonverbal cues and unsaid thoughts of the clinician. I am the course director for a course on medical documentation (Intensive Course in Medical Documentation: Clinical, Legal and Economic Implications for Healthcare Providers); 80 percent of the attendees are mandated to take it by their medical boards.

I suggest the potential use of a scribe (although I am thinking more in terms of a human one) as a tool to bring full attention back to the patient and to make the practitioner more time-efficient.

When I talk about this, I envision that there needs to be some alteration in how you talk with the patient, being cognizant that the scribe, human or AI, is passively listening. For instance, I recommend that when clinicians examine the patient, they verbalize aloud what they are doing and seeing. I suspect that patients would like to hear most of this, because most of the physical exam is usually normal.

But what if you notice a scary mole or palpate an ominous mass? If you don’t mention it, the scribe won’t know it is there, but if you do note it out loud, it could alarm the patient. The provider may prefer to discuss it when they are talking about the plan.

The discussion of the medical decision-making (MDM) has to be much more robust if the clinician is counting on the scribe/AI to document it for them. Their professional fee may be based on the MDM if they are not doing time-based billing. Do they need to articulate everything with the patient on the front end, though, or do they need to manually augment the documentation after it is available?

It seems as though it could be difficult to keep track of what needs to be added. But we should keep in mind with Open Notes that the patient can review the documentation anyway, so whatever we think is relevant and should be in the note, they are going to be privy to it.

There were a couple other fascinating points in this article. A surprising one to me was that “the federal Health Insurance Portability and Accountability Act (HIPAA) does not require providers to inform patients that their face-to-face conversations are being recorded.” It is possible that your state law does mandate it, however. I think it is best practice to let the patient know regardless of the regulations, and give them the opportunity to opt out of AI scribing.

The other key point stems from the observation that if you asked five providers to document the same patient encounter, you’d get five different notes, and it might be hard to judge the “accuracy” of the AI’s note. This piqued my interest because I am constantly trying to make my medical documentation course even better, and an idea we recently came up with was to have our attendees view a simulated patient encounter, compose a note, and discuss it in small breakout sessions. After assessing the quality of their documentation, we plan to demonstrate how they would level-set the evaluation and management service based on their notes. Similar to the fact that we recognize that we are going to get multiple different versions of the same encounter, depending on how the encounter unfolds, the AI rendering may need significant editing to represent what the clinician experienced.

The most important recommendation I have to make is that however a document is composed, be it via voice recognition, by a trainee, or by a human or computer scribe, it is incumbent upon the provider to read, edit, and revise it to ensure it accurately describes the patient encounter. And, seeing how badly we are at performing this task with copying and pasting, I am worried.

I am not ready for HAL 9000 to do everyone’s documentation quite yet.

Programming note: Listen to Dr. Erica Remer every Tuesday when she cohosts Talk Ten Tuesdays with Chuck Buck, 10 Eastern.

Why Words Really Do Matter in Medicine

By Erica E. Remer, MD, CCDS

When I was seeking a residency spot, I stayed in Chicago at a friend’s house who also was pursuing emergency medicine. She interviewed the week before me at the same program. Part of the interview was a case simulation posed by the faculty member, of a patient who had a pulmonary embolism (PE) and needed to be admitted for treatment. My girlfriend asked if I had the same mock scenario where the patient signed out against medical advice.

My role play was of a woman with a PE, but I had asked her why she wanted to leave. She replied she had to pick her child up from school. I asked if there was someone else we could call together to pick her daughter up instead, because I was very worried about her and she could possibly die from the blood clot. Then she would never be able to pick her daughter up again. My patient had agreed to be admitted. I ended up in the residency program; my acquaintance did not. The words we used mattered.

I recently read an article in JAMA by Jacqueline Kruser, Justin Clapp, and Robert Arnold called Reconsidering the Language of Serious Illness. This article was based on the concept that when we, as clinicians, use the word “need,” we convey an imperative to patients and family members which may be contrary to what we think would be in the best interest of the patient. They used the example of a patient with advanced cancer in an intensive care unit whose daughter was told that her mother needed to be placed on a ventilator or she would die that day. The daughter felt that the physician was making the best call for her mother, and if her mother needed to be intubated and ventilated, that must be the right course of action.

The authors’ recommendation was to avoid the word, “need,” and to replace it with a description of the problem (Your mother’s breathing is getting worse). Then they suggested verbiage like, “Can we talk about what this means and what to do next?” It seems as though, “Can we talk about what this means?” would give the family permission to understand the implications, react, and work through their emotions. “What to do next” gives the space to offer extraordinary measures but also the ability to give permission to not act, to choose comfort care or palliation.

The takeaway is that when we have the urge to use the word, “need,” we should consider framing the discussion differently. Something important is happening, we need to think about what it means, and what all the options are. We need to provide the patient and their loved ones with the information they require to make the decision that is right for them.

I think this type of scenario is often encountered when a patient is in dire straits and nearing the end of life. It reminded me of the times in the emergency department when I did the atypical act of discussing end-of-life care and opting for hospice. Of the time I was at Walmart and some family member of a patient I didn’t recall ran up to me to thank me for having broached the subject and let her mother die a peaceful death instead of undergoing painful (ultimately) futile procedures. Sometimes it is just in the way we present it.

An article in the Journal of Medical Ethics (“Allow natural death” versus “do not resuscitate”: three words that can change a life) poses changing the expression from “do not resuscitate” to “allow natural death.” “Do not resuscitate” sounds like you are withholding something that a patient might want. It is an action in the negative – don’t do something. “Allow natural death” is a positive action, and it frames it in a positive light. They both refer to the same action, but one seems more desirable than the other.

It is also a function of the general population having unrealistic expectations. Most medical fiction portrays resuscitation as routinely successful and never describes how painful or futile the procedures can be. Ah, the word “futile.” This led me to a set of papers about the “painful decisions that must be made when a life is nearing its end,” focusing on the concept of medical futility or perhaps, inadvisability (What’s the Point? Clinical Reflections on Care that Seems Futile). The pivotal word here was “futile.” They pointed out that futile means the action inevitably wouldn’t work, whereas most of the time what we really are trying to convey is that an action is, in our opinion, medically inadvisable.

Who gets to make that decision? Who judges quality of life? Should survival be allowed to be the sole goal? Who gets to decide how small a chance is too small? Is a provider obligated to offer therapy which they believe will be futile? Can factors like predictable suffering or likely disability or financial hardship enter into the decision?

The last article I read was by Debra Mazza called “Your Son Is a Very Sick Boy: What One Says Matter.” It is a devastating depiction of the author’s experience of losing her 19-year-old son. She was a counselor at a hospice agency and understands doctor-speak but expressed how words chosen to convey the gravity of a medical situation can still be misinterpreted. “Sick,” “stable,” “recovery,” “wake up,” and “get better” may not mean the same thing to a family member as intended by the medical staff. Her message was that words need to be chosen carefully and are impactful.

My expertise is in documentation.

It is my belief that the words we use in documentation matter. It is why I would like to see providers put MENTATION in their documentation. I hope I have also demonstrated that the words we clinicians use directly impact the patient and family’s choices and the quality of medical care the patient receives.

Programming note: Listen to Dr. Erica Remer every Tuesday when she cohosts Talk Ten Tuesdays with Chuck Buck, 10 Eastern.

It’s Official: CMS Recognizes Homelessness as A CC

By Tiffany Ferguson, LMSW, CMAC, ACM

As reported back in April 2023 regarding the proposed ruling on social determinants of health (SDoH) Z-codes, I would like to update and celebrate the final ruling for Z59.00, unspecified homelessness, with subcategories of 59.01, and 59.02- sheltered and unsheltered homelessness. These will now be considered a complication or comorbidity (CC), based on the higher average cost to care for such individuals.   

There were several comments and responses called out in this decision I thought were noteworthy to discuss (details are discussed from 293-309).

Commentators and the Centers for Medicare & Medicaid Services (CMS) concurred that greater alignment is needed between the SDoH quality submission requirements and SDoH Z-code capture, both recognizing that making homelessness a CC is a great first step, as this directly correlates with the social driver housing domain.

CMS also confirmed that they are continuing down the path of SDoH Z-code methodology for data capture to measure the impact on resource consumption, such as clinical evaluations, extended length of stay, increased nursing care, and comprehensive discharge planning, which is why continued collection is imperative for future analysis regarding reimbursement. There were requests for planning on future considerations for Z-codes to be considered as CCs/MCCs, but CMS shot this down, essentially saying they do not have enough data yet to make any statements. I would say that with the inclusion of questions regarding food insecurity as a social driver and the existing workflow for malnutrition in the coding and clinical documentation improvement specialist (CDIS) arena, this may be an easy alignment for coding, Z59.41, based off patient responses in the screening tool.

It was also noted in the final ruling that continued feedback regarding the addition of Z-code capture does not allow for enough space on the claim form, as we are limited to 25 diagnoses. CMS noted that this is not a part of their purview, and that these requests would need to be taken up with the National Uniform Billing Committee (NUBC) for adjustments to the UB04 data set and form.

Finally, commentators discussed concerns with their electronic health records (EHRs) and electronic coding tools, expressing a desire to stay up-to-date with Z code-recognition and capture. CMS stated that on April 18, the Office of the National Coordinator proposed updating certification standards that if finalized, would require certified EHR vendors to include four SDoH data elements in their products: SDoH assessment, goals, interventions, and problems/health concerns.

I am excited to see the continued momentum toward recognizing the SDoH of our patients and how this impacts their medical care and system resource utilization. If hospitals and health systems have not already begun this process, they should start working on determining how they are going to increase Z-code capture and really start pushing their electronic coding vendors to make sure they are updating their tools for coders and CDISs.

Programming note: Listen to live SDoH reports by Tiffany Ferguson, every Tuesday on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer.

References:
https://public-inspection.federalregister.gov/2023-16252.pdf

Why it’s Time to Retire the Term Non-Compliant

By Tiffany Ferguson, LMSW, CMAC, ACM

Non-compliance in healthcare typically means a patient who intentionally refuses to take prescribed medication or does not follow treatment recommendations. This term is often used in medical documentation as physicians and/or care team professionals categorizing patients in the “not doing what I say” category. The effects of this term projects a picture of intentional negligence by the patient, placing blame on their choices. Non-compliance was once a more popular term used in the medical community to remove perceived risk from the provider, however, recent research has created a different picture. According to research from Sous, W., Frank, K., Cronkright, P. et al. (2022), the term “non-compliant” has been shown to compromise care, particularly for marginalized communities. Ethically, this term has failed to demonstrate a provider’s respect for patient autonomy and has created a reverse effect of the “do no harm” mantra.

So, let’s give a hypothetical example: Mr. Jones has been placed under observation services at the local hospital for evaluation of his chest pain. Mr. Jones lives alone, about 20 miles from the hospital where he is seeking care. While working outside, he started having shortness of breath and chest pain, leading him to call 911. At the hospital, the care team starts running numerous tests on Mr. Jones, but all he can think about is his land and his animals back home. Mr. Jones is concerned about his heart, but was just hoping for some medication and to be back on his way. He really doesn’t like doctors’ offices, much less hospitals, and has spent many years avoiding them. When the physicians come in the room, they tell him what they are doing using hard-to-understand medical terminology. The nursing staff have been giving him medications and hooking him up to machines again with confusing medical terms. Mr. Jones has now been at the hospital overnight and although he is feeling better, he does not see the need to stay. He has his animals at home that need to be fed and he wants to take care of his property. Mr. Jones requests to leave. At this point, all efforts kick in from the hospital as they term Mr. Jones as wanting to leave against medical advance, AKA, the AMA discharge. They document his behaviors as non-compliant in the medical record,  rather than diving into the misconception of the AMA discharge and Mr. Jones’ concerns. I will say that Mr. Jones agrees to help with his discharge and get the information he needs for follow-up care, and the care team even helps coordinate a ride home. However, the labeling in his record stands. He is a “non-compliant patient with an AMA discharge.”

The scenario creates the picture that our lives are filled with competing priorities and stressors. With the best of intentions, the non-compliant patient does not take their medication because they do not have the money to do so. The non-compliant patient misses their doctor’s appointment because they have no transportation or maybe the city bus was late. As a healthcare community, rather than labeling our patients based on our own perspective of privilege, we should use the situation to ignite a call to action that we may have overlooked a valuable piece in our patient’s healthcare needs. What if, instead of just assuming the patient is simply not following medical advice or making their medical care a priority, we consider the following:

• Break down the process into more manageable steps and apply such methods as teach-back to assess the patient’s understanding of their healthcare requirements.

• Evaluate the patient’s motivation toward their care and potential barriers they may be dealing with.

• Assess for social determinants and cultural considerations that may make the information provided or their treatment requirements difficult to follow or comply with.

• Encourage patient input and feedback to generate their own ideas and suggestions into their care needs.

I would imagine in our lives at one point or another we all could be labeled as non-compliant and in the busy schedule and demands on our healthcare system sometimes it is easier to write “non-compliant” than figure out the reasons why. However, this impacts access to care and healthcare outcomes for our patients.

References:
Sous, W., Frank, K., Cronkright, P. et al. Use of a simulated patient case and structured debrief to explore trainee responses to a “non-compliant patient”. BMC Med Educ 22, 842 (2022). https://doi.org/10.1186/s12909-022-03894-7

Must We Wait for the Pathology to code malignancy?

By Erica E. Remer, MD, CCDS

This article was inspired by an article I read by Cynthia Tang and Richard Pinson (https://libmaneducation.com/coding-of-possible-malignancy-diagnoses-when-the-pathology-report-is-pending/). They expressed their concern about Coding Clinic’s advice to code an uncertain malignancy diagnosis when the pathology report was pending (Be aware that their article referenced 2023 Second Quarter, but the question and answer really appeared in First Quarter. I’m a little mortified that I didn’t pick up on this issue when it first appeared!). The question regarded a “liver mass, possibly hepatic cholangiocarcinoma,” and the documentation also indicated that the pathology was still pending.

Coding Clinic advised that this did fall under the purview of ICD-10-CM Official Coding and Reporting Guidelines, Section II.H. (https://www.cms.gov/files/document/fy-2024-icd-10-cm-coding-guidelines.pdf), Uncertain Diagnosis. As we know, this guideline allows for the coding of an uncertain diagnosis qualified with a word like, “probable,” “suspected,” “likely,” or such, if the condition has not been ruled out prior to discharge or demise, on the inpatient side. Coding Clinic recommended assigning C22.1, Intrahepatic bile duct carcinoma in this case.

The idea behind the uncertain diagnosis guideline is that the resources utilized to rule out a condition are similar to the resources used to rule it in. The Diagnosis Related Group (DRG) payment system is based on a statistical model recognizing that a given principal diagnosis, in the context of accompanying secondary diagnoses, predictably costs a certain amount of money to work up and treat. If a patient has an infiltrate and you still believe it is due to pneumonia at the time of discharge, then the insurer paying your institution for a pneumonia DRG is reasonable.

It is interesting to use Simple Pneumonia and Pleurisy as an example. This is a three-tiered DRG (MS-DRG 193, with MCC- RW 1.3235; 194, with CC- RW 0.8190; 195, without CC/MCC- RW 0.6224). Let’s say the provider decides it was acute bronchitis and not pneumonia. That would land in MS-DRG 202, Bronchitis and Asthma with CC/MCC (RW 0.9527) or 203, without CC/MCC (RW 0.6927), depending on the associated secondary diagnoses. If the final diagnoses ended up being cough and fever because pneumonia was ruled out and no alternate explanation was offered, MS-DRG 204, Respiratory Signs and Symptoms, (RW 0.8196) would be assigned. Depending on the comorbidities, Simple Pneumonia and Pleurisy may not be the most favorable DRG, so routinely making an uncertain diagnosis because some administrator suggested you get paid more might not be the best plan.

For many uncertain diagnoses, there may be no way to ultimately determine a definitive diagnosis. There may be no conclusive way to prove it. No gold standard diagnostic criteria, no cultures, no imaging. It may come down to clinical judgment.

However, a mass which gets biopsied is a different story. There is a way to resolve the uncertainty.

We teach our providers to float an uncertain diagnosis of malignancy if that is their (strong) suspicion, so that we can avoid having to query them if the pathology returns positive. My position has always been that this is important to get right for more than landing in a more favorably reimbursed DRG.

The story of the encounter is not accurate or complete if a patient was found to have a malignant neoplasm, but it was not documented and captured. The pathology report should resolve the uncertainty.

In fact, if the provider were to make an uncertain diagnosis of malignancy and the pathology were to return negative, the correct reaction would be to query the provider for clarification to remove the diagnosis, if appropriate. The clinician would need to determine if they still believed there was a malignancy (the biopsy could have missed its mark and be misleading) or if they believe the diagnosis should be amended.

Pinson and Tang point out that it has “always been an HIM and coding practice that coding is not completed or final billed until the pathology report is available for inpatients, particularly to confirm a malignancy diagnosis.” They refer to not coding unconfirmed HIV infection, but I don’t think that is a good analogy. HIV, Zika, COVID-19, and certain identified influenza viruses are only coded as “confirmed cases” but you don’t have to have laboratory proof.

The provider’s assertion that the patient has the condition is sufficient. You are just advised to not code uncertain diagnoses of these conditions.

Is it premature to drop the claim before the pathology results return? Should the institution have a policy that the pathology needs to be reviewed prior to billing? I guess it depends on how long the typical pathology turn-around time is, how good the clinician is at suspecting malignancy diagnoses, and how irritated they will get at receiving a query to potentially reverse their diagnosis.

My opinion is that being branded as having a malignancy has profound implications and it would be preferable to hold encounters with pending pathology to ensure accuracy. If a patient dies, transitions to hospice, or declines a work-up, then an uncertain diagnosis resulting in coding a malignancy without confirmation might be appropriate.

Programming note: Listen to Dr. Erica Remer every Tuesday when she cohosts Talk Ten Tuesdays with Chuck Buck, 10 Eastern.

The Role Of Implicit Bias on Health Equity

By Tiffany Ferguson, LMSW, CMAC, ACM

---

STAT News recently published an interesting series on a report released in 2003 by the National Academies Press, titled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health. The release was groundbreaking at the time, focusing on the realities of racial disparities for both the provider and patient sides of healthcare. However, as STAT News reports, over the last 20 years, not much has changed, as it pertains to racial health disparities and associated health encounter outcomes. Although the conversations have been more frequent and in-depth, and data now often examines race, improved health has not been achieved.

As I review these articles and see the momentum, we are making in areas such as those covered by the social determinants of health (SDoH), it should be clear that poverty should never conceal racial health disparities that exist in our healthcare system. These racial disparities span all socioeconomic and education levels. On July 12, the New York Times published details from a United Nations report that concluded that racism and sexism were the primary attributes contributing to maternal deaths of Black women – not genetics or lifestyle choices. “Black women in the United States are three times more likely than white women to die during or soon after childbirth,” their article read. “Those problems persist across income and education levels, as Black women with college degrees are still 1.6 times as likely to die in childbirth than white women who have not finished high school.” Putting aside our overt racial issues (such as the recent U.S. Supreme Court ruling regarding affirmative action), I can’t help but continue to call attention to the subject of implicit biases and their impact on our progress. Implicit bias occurs automatically and unintentionally, passively influencing our judgments, decisions, and behaviors.

Last year, Forbes contributor Dana Brownlee wrote an op-ed piece that challenged one implicit bias concept in particular: a common refrain by white individuals that color does not matter (often said to appease our own sense of discomfort when it comes to race). Brownlee’s article, titled Dear White People: When You Say You “Don’t See Color,” This Is What We Really Hear (forbes.com), noted that when individuals say that “people can’t make an impact on what they don’t see … people can’t address what they don’t acknowledge. People can’t affect change around what’s already been dismissed. I can guarantee that if a person is holding on to an ‘I don’t see color’ worldview, they are not doing too much of anything to move the needle on racism.”

So, in my initial example regarding racial inequality for Black maternal health, what if we start by automatically flagging Black women as being at high risk in maternal care, requiring access to additional care and services to ensure that they receive the necessary support they need? This is a detour from our prior notion that we cannot flag patients, because this will lead to labeling. But in doing so, are we failing to acknowledge the role that race is playing in our poor health outcomes? Additionally, data pertaining to hospital health outcomes, nationally and locally, should not only include reference to poverty, but reviews should include examination for racial disparities across all indicators.

The first step to address race as a health inequity is to acknowledge its existence and take the necessary steps to represent it as a health risk factor that requires additional attention and treatment.

Clinic Overflowing with Helpful Guidance

By Erica E. Remer, MD, CCDS

---

Today I am going to go over what I picked up from the American Hospital Association’s (AHA’s) Coding Clinic for the second quarter of 2023. It was chock-full of interesting advice.

Two weeks ago, I went over COVID-19 screening. I think Coding Clinic should have explained why we continue to use Z20.822, Contact with and (suspected) exposure to COVID-19 after May 11, instead of just noting that “this advice is consistent with current coding guidance.” In theory, once there is no longer an epidemic or pandemic, we should be using “contact with” and “suspected exposure” only when we recognize that is the probable scenario. In practice, they are setting the timeline as the end of the fiscal year in which the pandemic ended (that is, 2023).

I learned a new code in my review! There is a code, R97.21, Rising PSA following treatment for malignant neoplasm of prostate. This offers a solution on how to code biochemically recurrent prostate cancer, post-prostatectomy, and salvage radiation therapy. The Coding Clinic indicated that, since the prostate had been resected, the culprit has to be a metastasis, and since the site is unknown, you can use C79.9, Secondary malignant neoplasm of unspecified site. My new code is also used because that was how they diagnosed it – that is what “biochemically recurrent” means.

A question was posed regarding a patient getting a workup for a suspected malignancy, when an excisional biopsy of a supraclavicular lymph node revealed metastatic non-small cell lung cancer. The question related to the sequencing of the primary and secondary malignancies. Although the procedure is ostensibly linked to the secondary malignancy, the primary malignancy is the condition responsible for both the metastasis and the overall workup/hospital admission. The response is to sequence the primary lung cancer as principal diagnosis (PDx). One should only sequence metastasis as PDx if it is the only focus for diagnostic or therapeutic treatment.

An interesting question was asked about venous thoracic outlet syndrome causing left upper extremity swelling and acute left subclavian deep vein thrombosis. The indexing led to G54.0, Brachial plexus disorders, but the questioner proposed I87.1, Compression of vein, as a more accurate clinical representation. The reviewer agreed that since the pathology involved the vein, not nerves, further research should lead the coder to I87.1. To my clinician brain, “compression” usually indicates external forces impacting on the anatomy, like a tumor pressing on the trachea. However, ICD-10-CM indexes kink, obstruction, stenosis, and stricture to “compression of vein,” too.

On page 10, there is a question about a patient with pre-existing Type 2 diabetes presenting with hyperglycemia believed to be secondary to autoimmune diabetes after initiation of immunotherapy medication. The answer was to use only E11.65, Type 2 DM with hyperglycemia and T45.1X5A, Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter, for the exacerbation of the disorder of sugar metabolism. I couldn’t help but wonder – where would you go if there were no underlying, pre-existing Type 2 diabetes? In that case, the diabetes code would be E09.65, Drug or chemical induced diabetes mellitus with hyperglycemia.

Page 15 features a question about a post-abortion complication. A patient presents for an elective termination of pregnancy due to a genetic abnormality and sustains uterine atony and hemorrhage. If there were a post-abortion code analogous to O72.1, Other immediate postpartum hemorrhage, that would be the right choice. However, since there is not, the advice is to use O04.6, Delayed or excessive hemorrhage following (induced) termination of pregnancy, plus the code for the maternal care for the chromosomal abnormality. Currently, there is an Excludes1 note at O04 precluding concomitant use of Z33.2, Encounter for elective termination of pregnancy, but this will become an Excludes2 on Oct. 1. For this particular code, it makes sense, because excessive hemorrhage could occur at the time of the encounter for the termination (or could be delayed until a subsequent visit).

My final comment is that the reason why linkage is assumed resulting in the “with” guidance is that the conditions with the assumed causal relationship are commonly associated, not because the ICD-10-CM classification mandates it. It is the other way around; ICD-10-CM acknowledges the near-inevitable relationship between, for instance, hypertension and heart failure, or diabetes and chronic kidney disease, by assuming causality unless specified otherwise. The words “due to” do establish the relationship if the provider documents them (e.g., hypertension due to hyperthyroidism à I15.2, Hypertension secondary to endocrine disorders).

Please review the Coding Clinic guidance yourself. There are more nuggets to collect.

And I’d like to extend an invitation to all to join me on LinkedIn on Thursday at 1:30 p.m. EST for my next “Ask Dr. Remer.” You can find the link on my company page, Erica Remer, MD, Inc. Hope to see you then.

Getting Down to Brass Tacks with Providers About Documentation

By Juliet Ugarte Hopkins, MD

---

When I was a medical student in the late 90s, one of my attendings sectioned off a third of the sheet of paper in the medical record before me and instructed my note could not be larger than that area. Overwhelmed with a desire to capture every point about the patient’s story and condition which I considered of interest, I proceeded to write in tiny text so two lines fit into every one printed on the lined paper. While this memory makes me chuckle, it also reminds me of one reason why we continue to have such an issue with inadequate provider notes.

Back in the day, brevity in medical documentation was practically a badge of honor. You’ll be hard-pressed to find a physician between the ages of 40 and 80 who doesn’t remember at least one “legend” who kept a rolodex in their clinic office with a single index card per patient. Not per patient encounter – PER PATIENT. And, let’s be honest, who hasn’t rolled their eyes at a hospital surgical note which is a single sentence long?

Documentation started out as a record of patient condition for the documenters themselves – reminders of what they saw and addressed the visit before. With the rise of sub-specialization and team-approach medicine, office and hospital notes evolved into a type of communication using abbreviations and symbols which required special education to decipher. At the time, passing information between practitioners was of primary importance and the main reason for documentation. Everyone was on the same page (literally, before the development of electronic health records), and was kept in the loop with the plan for the patient.

When the purpose of documentation melded into the support behind reimbursement and quality monitoring, no one really explained this shift to the doctors and other providers. I stopped practicing clinically in 2014 and it was about a year before that when my group of pediatric hospitalists first spoke with someone “in the billing department” about specificity of documentation for patients with asthma and avoiding the term “urosepsis.” What was the reasoning behind this direction? “To make sure the documentation is as specific as it can be.” As you might expect, my colleagues and I were unimpressed. In fact, I did not understand what was REALLY being said until after I became a physician advisor working closely with utilization management and clinical documentation integrity teams.

Why? Because no one took the message down to brass tacks. Provider terms do not equate to coding terms and without proper coding, there is no proper payment to the hospital. Without proper payment to the hospital, services our patients need can’t be afforded. Without the ability to provide services our patients need, they would divert elsewhere and ultimately, the hospital will close. And, we haven’t even touched on quality and things like expected length of stay and outcomes….

My hope is that within the last ten years, the message about clinical documentation integrity has grown more to-the-point. But, I know the reality involves a continuation of many, many doctors across the country not understanding why they are being asked to “beef up their documentation.” How can you help with this effort?

Before anything else, it’s crucial to understand, appreciate, and empathize with the unavoidable fact that physicians, first-and-foremost, are most concerned with providing medical care to their patients. I’m talking about face-to-face conversations, hands-on examinations, and complex rumination about the assessment and subsequent plan. These actions which lead to actual stabilization or improvement of a patient’s medical condition are paramount to the physician. RECORDING these events will always feel like busy-work at best and an utter waste of valuable and increasingly limited time, at worst. When speaking with a provider for the first time about documentation issues, I make it clear we are on the same page about this and have no disagreement.

My next introductory point to providers involves the hard truth of the times they are practicing in. “The business of medicine” is no longer something physicians can avoid. Period. While in years and decades past, those in the white coats could leave things like hospital and patient finances to “the suits,” those days are gone. Like with any business, non-profit or not, if there isn’t enough money coming in to pay for the services provided, the services can’t be provided. Since all billing and subsequent reimbursement is based on what providers include in the medical record, there is no getting around physicians having a great deal of responsibility for the financial health of their clinics, hospitals, and health systems. Make no mistake, providers HATE this connection. Many, if not most, believe provider documentation should solely remain as communication between the care team members and not be relied upon for creation of the bill for services. Especially in the evolving world of artificial intelligence and electronic health records, there is a strong belief that there must be other ways to create an accurate bill without getting the providers into the fray. Unfortunately, at the current time, there is not. There is no wiggle room, here.

All physicians believe they provide the best care possible to their patients, but the death of paternalistic medicine brings the need to track and demonstrate truth in outcomes. It would be ridiculous to bunch stats for the Major League Baseball team based on the North side of Chicago in with those for the Olentangy Little League travel team in Ohio simply because both are named the “Cubs.” Likewise, not all “asthma exacerbation” is the same and expected to follow the same treatment and recovery path. If the subtleties of asthma type are not elucidated in the record, you’re going to have the equivalent of Wrigleyville players’ reported performance on SportsCenter leading to 75% pay cuts for each and every Cubbie.

Physicians have long referred to patients as “theirs.” “One of my patients really turned the corner and I’m so happy I can discharge him before Halloween,” is for certain a sentence I have uttered in my clinical past. We are personally invested in the care of our patients but this mindset must expand beyond the patient themselves and beyond the day-to-day plan. Make sure your providers know that providing the best care means keeping that care available in the area. Just 20 years ago, the threat of the local hospital closing was not on the mind of many in healthcare. Hospitals were a staple entity, a pillar of their communities which were possibly a presence for 100 years and expected to stick around for at least 100 years more. Now, dozens of hospitals close a year and even more reduce or eliminate specific services entirely due to lack of funds. Like it or not, justified or not, these funds are dependent on provider documentation in multiple ways.

Physician notes no longer simply serve as communication between medical team members. They are the very basis of ensuring patients receive safe, quality, effective healthcare and the foundation of reimbursement to the clinics, hospitals, and other facilities which allow patients to receive this care. Is this a heavy lift? Absolutely. Should we reconsider daily provider patient loads to allow sufficient time for this critical responsibility to be accomplished well? Something to consider….

About the Author

Juliet B. Ugarte Hopkins, MD is President of the American College of Physician Advisors, founder and CEO of Velvet Hammer Physician Advising LLC, and a member of the consulting team for Phoenix Medical Management, Inc. Dr. Ugarte Hopkins practiced as a pediatric hospitalist for a decade in Illinois, then developed the physician advisor role for case management, utilization, and clinical documentation at a three-hospital health system in Wisconsin. She was the first physician board member for the Wisconsin chapter of the American Case Management Association (ACMA), is a member of the RACmonitor editorial board, and is an author and national speaker.

What Two Factors Drive Huddles?

By Tiffany Ferguson, LMSW, CMAC, ACM

---

Generically, hospital multidisciplinary rounds, or “huddles” (I will use these terms interchangeably throughout the article) should occur at a consistent time and location for attendees to discuss patients’ discharge plans or progression of care needs. The true success of rounds relies on two factors: collaboration and accountability.

Just consider how often the following scenarios occur. Unit-based huddles take place with nursing, case management, and the physician advisor; however, the attending physician is absent because “they just can’t make it work.” Maybe their assignments are not unit-based, and thus they are on one unit when their patients are throughout the hospital (not at all conducive to rounds).

The second scenario is when the physician is in attendance, but they come in and run their list of patients while everyone else in the room listens. The physician must then direct the team for responses regarding patient care needs or discharge planning needs. In this case, it is not uncommon that the physician or hospitalist group has been “voluntold” that they are required to attend this daily meeting, in an effort to speed up the discharge process. In both cases, the value of the huddle to the physician is evident – minimally useful, meaning that in some cases, they find a way to completely avoid the process.

Collaboration

When rounds are rolled out, I typically see a list of items that “should be covered;” however, I rarely see a discussion with each stakeholder group that dives into the value and worth of rounds to each discipline. The goal of rounds is to get all attendees on the same page, ensure an inline approach for patient communication, and share relevant information with an outcome of reduced intrusions throughout the day. The physician does not want to attend rounds, leave, and then get multiple texts, phone calls, and secure chats from the very same groups that attended the rounds.

Through a collaborative process, the care team can identify the intention of rounds – discuss all patients for updates and progression of care, or only focus on up-and-coming discharges for preparations. In this case, the topics for discussion will be slightly different. A simple way to ensure that each member identifies his or her role in rounds would be to follow the “plan” approach:

Plan for the Stay (Physician);

Plan for the Day (Nursing);

Plan for the Way (Case Management);

Plan for the Pay (UR/UM, Physician Advisor); and

Plan for the Say (message to patients).

Accountability

Once the purpose of rounds or huddles is established, the next piece of the puzzle is to guarantee accountability of the stakeholders involved. Such phrases as “it’s my first day on” or “I didn’t review any of my patients yet, I just got here” are counterproductive to the process. On any given day of the week, it is each person’s first day on – that is why the rounds exist, to help each member get up to speed, so they do not have to start from scratch and reinvent the care plan. Thus, coming to rounds is critical; case managers or charge nurses that have not reviewed their patients or talked to their floor nurses for reports is unacceptable. If it is not possible to accomplish it in the morning, by the time rounds occur, move the meeting to a later time, when everyone can guarantee they are prepared.

During rounds, follow-up items and information is collected among the members; this may be to order changes or “to-dos” for the group. When members leave rounds, the expectation is that these items for follow-up will be completed. This ensures that the only further intrusions later in the day are new discoveries or changes to the patient plans of care.

Collaborative multidisciplinary rounds create the opportunity to enhance patient outcomes through coordinated approaches and optimized treatment plans. Although the team is moving in different directions throughout the day, from the patient’s perspective, the care team is all aligned, and making them feel safe in their plan of care. The team understands each member’s role and contributions in the care delivery process and is accountable to the collective success of the group. That connection develops at rounds or huddles, with each member understanding their role, their objectives, and how they are being held accountable for their deliverables.

Programming note: Listen to Tiffany Ferguson report this story live today during Talk Ten Tuesdays, 10 Eastern, with Chuck Buck and Dr. Erica Remer.

Are Hospitals Over-Consulting Physical Therapy?

Written By Tiffany Ferguson, LMSW, CMAC, ACM

---

A regular comment I hear from hospitalist medicine and case management staff is “we are waiting on the PT consult” or “we are waiting for PT to document their recommendations.” 

Physical therapists have experienced many of the same shortages since the COVID-19 pandemic began as the rest of the healthcare industry, with clinicians exiting the hospital setting and many going into alternative work environments for an improved work-life balance. Many hospitals have had to utilize contracted labor or physical therapy assistants (PTAs) for the majority of patient therapy needs, due to the limited PTs being stretched across the inpatient and outpatient hospital-based services to evaluate and treat patients. There are just not enough therapists to meet the demand. However, is such a demand required? Rather than increasing labor costs, should hospitals be asking themselves “are we over-consulting PT?” And is this leading to a delay in patient progression of care, not to mention unrealistic referrals for post-acute care?

In 2021, this topic was reported on by the Society of Hospital Medicine, which found that 38 percent of physical therapy consults were identified as potentially inappropriate. It is a well-known practice for hospitalists to place consults upon admission for PT and occupational therapy (OT), for early assessment and intervention of patients to assess mobility and post-discharge needs, even when there is no medical necessity for such consults. Once consulted, PT and OT are often unable to delete the inappropriate order, and instead will at least complete an initial assessment of the patient to assess their functional and mobility status.

One thing I wonder is if the metric and strong emphasis on fall prevention in hospitals across the nursing discipline and quality departments have created an unintended consequence for our patients and therapists. I often see large signs promoting how many days units have been “free from patient falls.” Patients who experience a fall have a quality report (and often a safety risk report) filed. Although this is an important process, it can still seem quietly punitive for the nursing unit or individual nurse. 

The easiest way to avoid the negative impact of patient falls is to keep patients in bed. In 2019, KFF News and The Washington Post ran an article warning of this exact issue: “Fear of Falling: how hospitals do even more harm by keeping patients in bed.” As if the title wasn’t pointed enough, they went on to note that “hospitals have become so overzealous in fall prevention that they are producing an ‘epidemic of immobility.’”

To identify a patient’s fall risk, we see patients receiving PT and OT consultations for safety and mobility assessments – then the mobility of the patient, unless independently ambulating, is up to the PTAs, who see the patient daily and get them moving. Instead of promoting mobility and walking in between the consults, nursing units place bed alarms on patients. 

From a hospital throughput process, the over-utilization of PT consults creates a large delay, especially for patients under outpatient with observation services (OBS) who are expected to have a quick turnaround, but are now delayed for mobility assessments, regardless if this is a contributing factor to their need for hospital observation services. The result of this consultation is then exacerbated if the therapy assessment recommends post-acute placement, triggering further delays for case management planning and arrangements.

To break the cycle of overutilized therapy consults for PTs who are under-resourced, hospitals should consider tracking the consult utilization of patients resulting in PT signing off on discharges home without services. This data represents a great first step to identify inappropriate consults. 

Dr. Martinez from the University of Chicago recommends patients receive a quick Activity Measure Post-Acute Care (AM-PAC) assessment prior to consulting therapy for patient assessment. Additionally, hospitals have started looking at bringing back patient care technicians and hiring mobility technicians to mobilize patients, rather than relying on the therapy department and supporting the multiple constraints in the nursing divisions.

There is no question that avoiding patient falls is important, but have there been unintended consequences resulting from overutilization of PT and limited patient mobility?

Programming note: Listen to Tiffany Ferguson’s live reporting on the social determinants of health (SDoH) today on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer, 10 Eastern

References

Bailey, M., (October, 17, 2019). Fear of Falling: How hospitals do even more harm by keeping patients in bed.” KFF News Retrieved from https://kffhealthnews.org/news/fear-of-falling-how-hospitals-do-even-more-harm-by-keeping-patients-in-bed/

Doyle, E. (January, 2022) Are hospitalists calling too many PT consults? Today’s Hospitalist Retrieved from https://www.todayshospitalist.com/hospitalists-calling-many-pt-consults/

Martinez, M. (August 18, 2021) Defining Potential Overutilization of Physical Therapy Consults on Hospital Medicine Services. Journal of Hospital Medicine (August 2021). DOI 10.12788/jhm.3673

When Did the Hospital Become a Pathway to Housing?

Written By Tiffany Ferguson, LMSW, CMAC, ACM

---

In my recent hospital travels, involving working with frontline case management staff, we completed an initial assessment and intervened with a patient who provides one example of the significant issues hospitals are seeing when it comes to social admissions. The patient was a 47-year-old quadriplegic male admitted with back pain. The patient had a significant trauma approximately five years ago from a diving incident that completely turned his life upside down and landed him dependent on family and governmental support.

The patient was admitted to the hospital under outpatient with observation services while his “back pain” was being evaluated. In reviewing the hospitalist history and physical examination (H&P) we learned that the patient was “hoping to go to skilled care until he could move into his brother’s house.” This is a red flag, from a case management standpoint, and warranted further investigation with the patient. 

During our conversation with this likable gentleman, we saw his predicament: his one brother, who is a paid caregiver, can no longer easily care for him due to his own age and debility. The patient’s other brother is now willing to take him in and care for him, but his home will need significant remodeling to handle the patient’s handicap needs. The patient believed that if he “got into the hospital,” he could either get greater caregiver support or go to skilled nursing while the home repairs were completed. When asking the patient why he believed the hospital would solve this problem, he stated that this is what he remembered his previous rehab physician telling him. 

This is one example of the systemic issues in our communities: there is a failure to intervene with patients, resulting in an unnecessary hospitalization, meaning that their social determinant, most often housing, can be solved in the hospital. Patients are sitting in beds in hospitals across the country, as we speak, because they are homeless and lack access to supportive shelters, because their home situation is inadequate, or because they require a pathway to long-term nursing care facilities. Time and time again, the hospital has become the answer to these determinants, rather than the community-based social services. 

Physicians’ heartstrings are being pulled with patients being admitted to the hospital, because their social situation is “not safe,” skewing the boundaries and definitions of medical necessity. This is by far the most expensive means to a necessary result to help these individuals, and unfortunately, the payor system does not support the need. In our fee-for-service world, this patient scenario will likely result in denied days for observation from his managed Medicaid plan. The hospital case manager and physician will then deal with the ethical dilemma of discharging this patient and many others back to their subpar conditions. 

This patient does not belong in a skilled nursing facility (SNF), nor does he have medical necessity for such placement. The easy answer would be to try anyways, but instead, the case manager and I spun our wheels trying to creatively find social-service and volunteer agencies to help this patient, while also trying to find his long-term care case manager. Our efforts were an attempt to get his caregiver hours increased and educate the patient on the realities of his health insurance and unnecessary hospitalization. 

This topic will continue to be an area of conversation by MedLearn Media, with Dr. Hirsch’s upcoming webcast regarding payment and compliance for the “Outpatient in a Bed” designation, as well as future webcast topics focusing on social complexities and methods for hospitals to handle such patients.

The initial answer involves figuring out how we can prevent the regular response of “go to the hospital” – and if the patient arrives nonetheless, how we delineate social complexities with unideal determinants from medical necessity.

Programming note: Listen to Tiffany Ferguson’s live reporting on the social determinants of health (SDoH) today on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer, 10 Eastern.