Q: Our coders and coding auditors often see patterns of incorrect physician documentation. Sometimes the error impacts the MS-DRG, but many times it does not. What recourse do we have to communicate our clinical validation concerns?
A: Your situation is certainly not unique. In a world where responsibility for clinical validation has been removed from the hands of coders, questionable or faulty clinical documentation creates a conundrum for coders and coding auditors.
In many cases, both the coder and auditor know the case may be denied due to missing clinical indicators, but find themselves with limited ability to correct the physician's documentation. This scenario is particularly troublesome for known RAC denial targets. Long-standing patterns are hard to break -- and their downsides are even more difficult to explain.
Two Common Coder Concerns
We experience the same challenges when conducting external audits for our customers. For example, we have reviewed records of physicians who consistently list severe protein calorie malnutrition but with no clinical indicators to support severe rather than mild, moderate or even unspecified. Even in cases where the patient displays several malnutrition characteristics, full compliance with severe malnutrition criteria sets may be lacking. Payers will definitely deny severe malnutrition without appropriate clinical indicators.
Another common scenario is using language that is similar but incongruous with approved terminology. For example, documentation of "chronic stage 3 kidney injury" versus "chronic stage 3 kidney disease." Coders know what the physician is trying to communicate, but coding N18.3, CKD stage 3 can be incorrect based on the physician's documentation.
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Facilities that have not gained support to conduct ongoing coding audits will have more difficulty recognizing poor documentation patterns. It's important to establish regular coding audits. We've seen that routine, consistent coding reviews are a key step in correcting faulty clinical documentation.
Five Tactics to Consider
While everyone in the industry awaits CMS clinical validation guidelines, here are five communication strategies to educate your physicians and begin improving documentation:
• Use coding auditor findings for education and feedback in a factual, nonjudgmental way with your medical staff.
• Share concerns about incorrect documentation patterns with your physician liaison or senior medical staff leadership for peer-to-peer discussions.
• Communicate concerns with your CDI team to gain their proactive monitoring and support.
• Engage external coding or documentation experts to present findings and educate your physicians. Sometimes consultants capture the ear of physicians more effectively than internal experts (even if the message is the same).
• Work with your coding auditors to develop a proactive communication plan when patterns of bad documentation habits are identified.
Use consistent coding guidelines and follow established communication processes to help your coding team -- and physicians -- achieve better coding outcomes and reduce the risk of clinical validation denials.
Kimberly Carr is director, clinical documentation, and Jonathan LaFleur, is an auditor, both at HRS.