Research and reporting going back nearly two decades suggests that hospital inpatients are increasingly sicker, and their care more complicated. Intuitively, this greater inpatient acuity should result in higher emergency department (ED) evaluation and management (E/M) service levels for those patients admitted through the ED. This article examines whether that circumstance exists and, if so, how clinicians and coders can use this information to improve coding and compliance.

Inpatient Acuity Is on the Rise

Studies agree that inpatient acuity has been increasing, whether measured against clinical or coding criteria.

In 1986, three years after the introduction of Medicare’s Inpatient Prospective Payment System (IPPS), Bruce Steinwald and Laura A. Dummit reviewed changes in hospital case mix. The results, published in Health Affairs (“Hospital Case-mix Change: Sicker Patients or DRG Creep?” May 1989, 8:p. 35-47), noted that some of the increase in case-mix acuity was a result of better documentation. The review also distinguished changes resulting from “increases attributable to patient need” or “‘real’ case-mix change.”

In part, the so-called “real” case-mix change was the result of less acute cases moving into the outpatient setting, thus leaving higher case weight (higher acuity) cases in the inpatient setting. Cataract cases provide one example (Health Affairs, May 1989, 8:p. 35-47):

“The shift of less complex cases to outpatient settings is particularly noticeable with the treatment of certain illnesses of the eye in DRG 39 (lens procedures). DRG 39 had a weight of approximately 0.57 in 1986, significantly below the average case weight of approximately 1.21. As these patients were moved to the outpatient settings for ambulatory surgery, the overall average DRG weight for inpatients increased. Medical advances have also led to increased acuity among inpatients. The increase in inpatient acuity has been reflected in the DRG coding.”

In a 1996 survey of registered nurses published in the American Journal of Nursing (AJN) (vol. 96, no. 11, p. 25-39), three-fourths of nurses indicated that the acuity of patients assigned to them had risen. Another study published in 2003 (Medical Care, “Licensed Nurse Staffing and Adverse Outcomes in Hospitals,” 41(1):142-152) similarly indicated that acuity increased 21 percent in Pennsylvania hospitals during 1991-1997, as measured by MedQual severity scores.

Many Inpatients Come from the ED

Many inpatients with increasing acuity come through the ED. An analysis of 2003 data by the Agency for Healthcare Research and Quality (AHQR) supports this, concluding, “65 percent of patients admitted on a weekend were initially seen in hospital emergency departments, compared with 44 percent of weekday-admitted patients” (AHRQ News and Numbers, “Patients Admitted to Hospitals on a Weekend Wait for Major Procedures,” March 4, 2010).

MDM as the E/M Service Level Pointer

For outpatient visits by established patients, as well as subsequent hospital care and other visits with established patients, the selection of the E/M code requires two of three key components—history, exam, and medical decision making (MDM)—under American Medical Association’s (AMA) CPT® guidelines. Many coders interpret the discussion on medical necessity in section 1862(a)(1)(A) of the Social Security Act to mean that MDM must be one of the two key components.

For example, consider an article that appeared recently in the American Academy of Family Physicians (AAFP) Family Practice Management Journal titled “Thinking on Paper: Guidelines for Documenting Medical Decision Making.” Authors Robert Edsall and Kent Moore quote Dr. Pat Price, medical director for Medicare Part B in Kansas and Nebraska, as writing, “It should be the complexity of the medical decision making process and the medical problem which is the most heavily weighted factor in determining the E/M service level.”

The AMA has not taken an explicit stand on this issue. The November 2008 CPT® Assistant indicates that the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services are not the AMA’s, but goes on to say:

“…any element of history and examination must be relevant to the care of the patient, not simply serve as documentation to support code selection. Each E/M service states, “evaluation and management of a patient which requires the key components…” [emphasis in original]

This implies history or exam elements should be recorded only to the extent that MDM requires them, which may be another way of saying MDM is always a required key component.

ED E/M codes require three of three key components to assign a service level. Based on the aforementioned information, when you determine the level of service, MDM should be the pointer.

MDM’s Influence on Level of Service

Because acuity among inpatients is increasing, and significant number of inpatients are coming through the ED, you can reasonably expect that ED patients who are admitted should have higher levels of E/M codes assigned, and that the validity of the coding can be tested by looking at MDM. Said differently, the assigned ED E/M code should be at a higher level (99285 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity or 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes)—and if it’s not, MDM should be checked to see if the original code was assigned as a result of error or documentation deficiency.

Put the Numbers to the Test

ED encounters at a 511-bed, 26-bassinet, adult, tertiary-care, not-for-profit, teaching hospital with 56,507 ED visits at its main facility ED were selected from three days in November 2009. Review of the coders’ posting logs identified patients who were admitted.

The facility admitted 16,381 cases from the ED in 2009; the three days’ ED admissions represent approximately 0.8 percent of all 2009 admissions from this department. Coding for those encounters was reviewed using 1995 guidelines supplemented by the Iowa Medical Society form (version 010198). This form has been used by the Ohio State Medical Association (OSMA) for its chart auditing training classes. Certified Professional Coders (CPCs®) completed the initial coding; a certified coder also completed the review.

On the first day examined, 40 patients were admitted. Of those, 37 were initially coded with either 99285 or 99291; 93 percent of the admissions were initially coded with an E/M code reflecting high complexity MDM and/or critical care. Review coding confirmed the initial coding. Of the three remaining encounters, one was not coded due to a lack of documentation at the time of the review. The remaining two were originally coded 99284 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity, reflecting moderate complexity MDM.

On the second day, 50 patients were admitted. Of those, 31 were assigned either 99285 or 99291; 62 percent of the admissions were initially coded with an E/M code reflecting high complexity MDM and/or critical care. Of the 19 remaining encounters, two were not coded at this facility because they were transferred from freestanding EDs to be admitted through the main ED. One was not coded due to a lack of documentation at the time of the review. Among the remaining 16 encounters, 12 had circumstances that pointed to high complexity MDM (see Chart A), but level of service coding was limited due to incomplete review of systems (ROS).

Exam documentation limited the level of service in another encounter, where the circumstances of the encounter pointed towards a higher level of service (see Chart A). Three of the four remaining encounters did not rise above moderate complexity MDM. The last encounter was review coded at 99285, one level higher than initially coded. The original coding for all other encounters was review coded consistent with the initial coding. Adjusting for documentation deficiencies and review coding, 88 percent of admitted patients on day two were (or should have been) coded with either 99285 or 99291 when MDM was used as the pointer to level of service.

On day three, 34 patients were admitted. Of those, 28 were coded with either 99285 or 99291; 82 percent of the admissions were initially coded with an E/M code reflecting high complexity MDM and/or critical care. Of the six remaining encounters, two were not coded at this facility because they were transferred in from freestanding EDs, as they could not be admitted through the main ED. On review of the remaining four, one was found to be appropriately coded 99284. Three had circumstances pointing to high complexity MDM (see Chart A), but level of service coding was limited due to an incomplete ROS. Adjusting for documentation deficiencies and review coding, 91 percent of day three’s admitted patients were, or should have been, coded with either 99285 or 99291 when MDM was used as the pointer to level of service.

Use the Correlation to Resolve Documentation Deficiencies

With a 90.3 percent overall rate, the modest sample of encounters reviewed clearly suggests that when MDM points to the level of ED E/M service among patients subsequently admitted to the hospital, that level will be higher. This conclusion is intuitively reasonable, since the studies reporting shows the acuity of admitted patients—measured by both coding and clinical measures—has been increasing.

ED compliance staff may want to examine level of service distributions of treated and released patients separately from those of admitted patients. Although this sample suggests higher levels of ED E/M codes are appropriate for these patients, it does NOT mean all admitted patients should be coded with the higher levels of service. It means clinical staff should be aware of this suggestion and document appropriately, consistent with their facility’s compliance guidelines. Coding staff should also know this, and help clinical staff to resolve documentation deficiencies.

William C. Fiala, MA, CPC, CCS-P, is an instructor for the University of Akron’s Allied Health Department. Beyond the university setting, his company, Fiala Analytical Services, Inc., assists clients with audits and compliance issues.

Nicholas J. Jouriles, MD, FACEP, is an academic emergency physician and is professor and chair of emergency medicine at Northeast Ohio Medical University. Dr. Jouriles is also a past president of ACEP.

Editor’s note: An expanded version of this article, complete with footnoted references, is available by contacting John Verhovshek, MA, CPC, at g.john.verhovshek@aapc.com.

A query is a communication tool used between facility coding personnel and the physician and/or other health care practitioners whereby the coder obtains additional documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in a beneficiary’s health record. The process may take place concurrently (while the beneficiary is in the facility) or retrospectively (after discharge).”

I find this very interesting because I have no idea what Medicare means when it instructs the Medicare administrative contractors (MACs), comprehensive error rate testing contractors (CERTs), and zone program integrity contractors (ZPICs) to “give less weight when making review determinations” to documentation created more than 30 days after the date of service.

Since when did something as vague as “give less weight” become an audit protocol standard? Does anyone on the Legal Advisory Board have any insight on this?

Robert A. Pelaia, Esq., CPC, CPCO

Senior University Counsel for Health Affairs, University of Florida College of Medicine, Jacksonville, Fla.

Answer

Here are the responses of AAPC Legal Advisory Board members:

—David M. Vaughn, JD, CPC, Vaughn & Associates, LLC

“I do a lot of appeal work, so I get questions about after-the-fact documentation all the time, and frankly, this rule is in line with the general rule I tell my clients: That is, at some point creating after-the-fact documentation is going to be viewed as too stale to be credible. Most of my clients can’t remember specific cases in the operating room (OR) that happened last week, much less last month, or last year. So, I’ve been telling my clients for a while that although they can add late documentation, at some point there will be a presumption that the information is too stale to be considered credible. That doesn’t mean there aren’t appeal rights to overcome the “give less weight” (whatever that means) standard.

In legal speak, I view the “give less weight” standard as a presumption of non-allowability in the audit phase. I believe it will be upheld in the redetermination phase by the MAC, and the reconsideration phase by the qualified independent contractor (QIC), but can be overcome in the administrative law judge (ALJ) phase when the doc is on the phone with the ALJ testifying under oath that he remembers this specific case. If he can’t remember this specific case, I think the presumption will be upheld.

While I don’t necessarily agree with the 30-day time frame, what I do like is that there is a specified time frame. I can tell my clients, ‘You’ve got to get it documented in 30 days or else the presumption is going to be that it is too stale for you to have remembered that.’

Robert, hats off to you for bringing this to our attention.”

—Michael D. Miscoe Esq., CPC, CASCC, CUC, CCPC, CPCO, CHCC, Miscoe Health Law, LLC

“This is consistent with the U.S. Department of Health & Human Services (HHS) Office of Inspector General/Office of Audit Services (OIG/OAS) audit process guidance regarding assessing the credibility of the information provided. Notwithstanding this provision, most ZPICs or QICs will cite the PIM Ch. 3 §3.4.1.2 (or a portion thereof) as a basis for completely ignoring supplemental information. Regardless, most ALJs will consider the information, especially where the doctor’s direct testimony is credible and the supplemental info does not conflict with information recorded contemporaneously.

I concur: ‘Give less weight’ is meaningless and likely improper. What it should demand is an assessment of credibility. Note that 3.4.1.2 is contrary, indicating that the date a record was created is essentially irrelevant.”

—Timothy P. Blanchard, JD, MHA, FHFMA, Blanchard Manning LLP

“I think the Centers for Medicare & Medicaid Services (CMS) is off base with this instruction and that provider comments to CMS are warranted.

Any valid (important point) medical record entry is entitled to full faith and credit. After all, it is backed up on the physician’s license (which could be lost if an entry were shown to have been false or fraudulent). While legitimate questions might be raised in connection with very late entries, either they are valid or they are not. There is no basis for either a sliding scale or a presumption of invalidity. As long as the authenticating physician has a sufficient present recollection of the events or observations he or she can properly make a late entry and it should be respected (given full credit normally afforded) if properly entered and authenticated.

I hope providers do not just cave in and accept this. Determinations based on this instruction should be challenged in the appeal process. From time to time late entries will be necessary for almost every provider and it should not matter what triggered the conclusion that a late entry was appropriate to assure an adequate and accurate medical record.”

—Julie Chicoine, Esq., RN, CPC, Senior Assistant General Counsel, Ohio State University Medical Center

“I have given this some further thought and suspect that the underlying issue turns on the issue of what I think of as ‘evolving documentation’ where coders or other support staff seek supplemental (additional) documentation from providers to clarify the services rendered during a particular encounter.

Documentation enhancement usually takes the form of addendums to the medical record. To me, this makes sense; though, if the contractors see too much of it—especially with one or two providers several days or even weeks after the original patient encounter, and when it follows an ADR—then it becomes suspect.

This might serve as a foundation for an excellent article or presentation on documentation improvement.”

The agency is seeking public input on this approach. Once posted, comments can be submitted for 90 days online or in writing to: Division of Dockets Management (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852. FDA says it will update the guidance based on the feedback received.

As we move into the era of pay for performance, value-based purchasing, and bundled or global payments, our documentation must represent clearly the services we perform, and the rationale and medical necessity for our actions.

Patient care and documentation of that care given by any provider should have four elements of focus:

• The patient
• Clear communication with other health care providers
• Quality, evidenced-based care
• Best resource use

Let’s review these points one by one.

The Patient

First, information is gathered regarding the patient using all possible resources. Information is derived from the patient, family members and other caregivers, past providers or charts, and from direct questions to the patient about a particular problem or impairment. Depending on the chief complaint, subjective questionnaires are used, such as the Visual Analog Pain Scale, the Oswestry Disability Index, or the New York Heart Association, Classification for Congestive Heart Failure, etc. This information should be recorded completely in the most concise format.

Next, the patient is physically examined for pertinent elements utilizing in-office investigational tools and objective measures, depending on subjective information. For instance, based on the patient’s presenting problem, the examination may include: heart and respiratory rates, blood pressure, height and weight, and temperature; objective reflex testing; objective sensation testing; auscultation of the heart and lungs; palpation of organs and arteries; range of motion, strength testing and specialized tests for joint stability such as Lachman or McMurrray’s tests; tests for gait and/or balance, such as the Tinetti Performance Oriented Mobility Test; otoscopic or specialized eye exams, such as slit lamp testing, etc.

Outside testing may be used if required, and if a rationale for medically necessary tests is provided—beginning with the most conservative and least costly alternatives, and always keeping in mind which procedures can provide the most information regarding a particular condition.

The physician or other provider’s decision making then comes into play as a conclusion is reached regarding the patient’s care plan. This is the most important part of the process. The rationale for the care used must be justified and be clearly quality, evidence-based care that is medically necessary for this patient, at this time.

Clear Communication with Other Health Care Providers

The next step is to document what was done. A clear picture should be painted of the above actions and intentions in a way that is evident to anyone who reads the medical record.

Ask yourself: Does the picture provided in the documentation have all of the required elements of form and substance? Does it have a focal point? Does it bring all of the elements together toward a conclusion? Is the picture of the quality wanted, or does it need revision? In documentation, the picture painted should be clear to other providers or suppliers who will see the patient in the future.

For instance: What was the patient like before the injury or problem? What problems were presented? Did the patient have problems with function or activities of daily living? Were there problems with cardiovascular endurance? Were open wounds documented, and if so, were they accurately described and objectively classified? Was there a language barrier or cultural barrier that needed to be overcome to treat this patient? Was the primary and any pertinent secondary diagnoses clearly documented? Does the reader know what has been done to investigate the patient’s problems and why a resource was chosen over another? There should be a reason for every ordered test.

What was done to alleviate the problems? Was the care plan the best care possible as recommended by evidence-based practice and utilizing the least costly resources to help this particular patient with this particular diagnosis? There should be a reason for hospitalization, home health, nursing facility care, outpatient services, or referral to another provider. Will the reader know how long the treatment plan takes and what the expected patient outcome is when the treatment is concluded? There should be a reason for how often a patient is seen and for how long, and a reason for the expected time frame of when the patient needs to return for another visit.

In short: Was medical necessity for their care demonstrated and documented?

Quality, Evidenced-based Care

In 1991, the Institute of Medicine defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and knowledge and are consistent with current professional knowledge.” Similarly, in 2009, the Centers for Medicare & Medicaid Services (CMS) published a “Roadmap for Quality Measurement in the Traditional Medicare Fee-for-Service Program.” The agency defines quality measure goals as:

“Safety—where care doesn’t harm patients.

Effectiveness—where care is evidence-based and outcomes-driven to better manage diseases and prevent complications from them.

Smooth Transitions of Care—where care is well-coordinated across different providers and settings.

Transparency—where information is used by patients and providers to guide decision making and quality improvement efforts, respectively.

Efficiency—where resources are used to maximize quality and minimize waste.

Eliminating Disparities—where quality care is reliably received regardless of geography, race, income, language, or diagnosis.”

In its quality program, the Physician Quality Reporting Initiative (PQRI), CMS “works with organizations, such as the Joint Commission on Accreditation of Healthcare Organizations, National Committee for Quality Assurance, Hospital Quality Alliance, Ambulatory Quality Alliance, National Quality Forum, medical specialty societies and many other organizations and government agencies including the Agency for Healthcare Research and Quality and the Veterans Health Administration, in the development and compilation of measures that have been tested and found to be reliable and valid in assessing quality.”

In England, pay for performance is a reality for its general practitioners. Pricewaterhouse Cooper’s Health Research Institute’s article, “Paying for Performance – Incentives and the English Health System” states, “Pay for performance (P4P) is becoming an increasingly popular mechanism for incentivizing quality improvement globally. P4P is the only mechanism whereby quality metrics are explicitly linked to reward, however. As such, it is arguably the most effective mechanism for incentivizing quality over activity and/or volume.”

What does this mean for the provider in practice today? When the decision is made for a test or an intervention or procedure, it should have a rationale defined by agencies with tested measures that exhibit consistency and reliability in the treatment of patients. When work is documented, such measures must be used to demonstrate medical necessity and establish that the best possible care is provided.

The health care system is moving away from fee-for-service and pay for volume of care and toward pay for performance. The PQRI program will soon be based on pay for performance instead of pay for reporting, and voluntary efforts will soon be mandatory. It is moving toward value-based purchasing, where you may earn back reimbursement by demonstrating quality outcomes across a variety of service places (hospital, office, hospice, home care, etc.). This applies not only to Medicare, but more recently also to many third-party payers. The only way to show that this quality and performance is provided is through clear and precise documentation.

Best Resource Use

One element of the CMS “Roadmap for Quality Measurement in the Traditional Medicare Fee-for-Service Program” is efficiency, in which the resources used will maximize quality and minimize waste. CMS is leading us into bundled payments with some of their demonstration projects, where physicians and different providers will work with hospitals and others to provide the best quality solution for their patients utilizing the least resources. Another way to reduce health care costs as a portion of overall Gross National Product (GNP) might be a global payment system in which providers manage patients across all delivery systems, earning reimbursement for how they care for their patients. This might include specific diagnostic groups using very specific guidelines for all patients, reducing the volume of services delivered overall.

The issue of transparency is not quality alone. CMS is already publishing procedure prices in various hospitals and will expand this to physicians in the near future. As consumers become more educated in these areas, competitive pricing and quality will determine market factors for patient choice, which should decrease overall health care costs. Documentation should include the least costly resource reasons for utilizing one testing method, procedure, or product over another, as well as what is best for the patient.

Follow the Practice Standards of your professional organizations. Follow local and national Medicare and Medicaid rules if you choose to receive their reimbursement. Follow the documentation standards of your third-party payers. All providers should be participating in or should begin to participate in the PQRI initiative, as this is part of the future of health care.

What About Malpractice?

If every diagnostic test and new technology available isn’t utilized, how can malpractice lawsuits be avoided?

If some time honored treatment that always has been done to protect a practice is provided unnecessarily with increased services or prolonged treatment time, then increased services and increased revenue of the old fee for service system is gone and quality treatment in care suffers, which is a malpractice risk. When best practices guidelines as outlined by national agencies and professional societies are followed, and documentation is clear as to why one test is chosen over another for being the best and least costly test to diagnose a patient, then the patient has received quality care.

Back to the Basics

It’s the patient that counts. If the above care and documentation is provided, everyone involved in every health system that a patient has or will encounter should understand what was done and the rationale for choosing a particular treatment plan and can carry out appropriate care from there. Everyone benefits from knowing the test and assessment results, and treatments and placements to avoid repetitious, unnecessary, and costly procedures. Documentation should demonstrate the quality and medical necessity of the care plan chosen over the continuum of the patient’s care and lifespan.