Getting Your Physicians to Document Effectively

February 5, 2013

CDI Blog - Volume 6, Issue 5

by Timothy N. Brundage, MD

Physicians resist change. They fear it. Although comfortable reading medical literature, and comfortable improving patient care with new techniques and medications, having CDI professionals “educate” physicians about improving their documentation habits makes them markedly uncomfortable. Physicians see such discussions and reviews as a threat to their autonomy. They view CDI efforts as the “evil administration” pushing them to document differently, which of course, adds to their discomfort.

Historically, physicians were not educated about proper documentation techniques. The entire CDI profession is relatively young and only recently a part of physicians’ daily practice. Addressing CDI queries certainly adds to the time required to care for a patient when CDI queries, along with pharmacy queries and core measure order sets, are all pushed into an already overloaded medical chart.

Professional Scrutiny
Regardless of previous experiences with documentation efforts and regardless of the additional effort it may necessitate, physicians’ response and cooperation is required. Why? Because unfortunately, physician scrutiny is increasing.

Currently, CMS is collecting data points on physicians. Such data is directly linked to the diagnosis documented by the treating physician in the medical record. The physician’s quality metrics will be measured and compared to other doctors in their same field.

Such results are already being posted on public websites such as Healthgrades.com, which reports data collected about individual physicians and can be easily accessed by patients. Consumers can read and review quality and morbidity/mortality data of physicians and compare those metrics to other physicians’ in the community. Accurate and thorough documentation will create reliable data that will reflect the high quality of care physicians provide.

Whether physicians want to hear about it or not, they need to understand that poor documentation leads to reduced reimbursement, increased claims denials, greater audit risk, inaccurate patient severity levels and inflated complication rates: all of which leads back to poor public reporting results.

Physicians must recognize they should get credit for the great care they are providing, and credit comes only through proper and thorough documentation reflected in appropriate coding. Following are examples of situations where documentation is critical to the healthcare process:

I. If a patient meets sepsis criteria, but is only diagnosed with a urinary tract infection (UTI), then the patient appears healthier than they really are. The patient with a UTI probably doesn’t even need hospitalization, but the patient who meets SIRS criteria and can therefore be diagnosed with sepsis is much more ill. This patient needs hospital admission and has a higher mortality than the ambulatory patient with a garden variety UTI. When documentation is lacking, the patient appears to have a lower mortality risk than is truly present. This can lead to physicians having inaccurate mortality rates when compared to their peers.

II. Physicians must understand that sick patients require more resources for their medical care. These patients require more laboratory tests, more radiographic imaging and more nursing care. The physician needs to document correctly so the true severity of illness is captured. This will allow the patient to have higher relative weight through MS-DRG assignment. The hospital then has more assigned resources to care for this sick patient. The hospital will be correctly reimbursed for this increased utilization of resources if the physician documents the true severity of illness through diagnosis-based coding language.

III. Proper assignment of MS-DRGs also increases the amount of time the patient is expected to stay in the hospital. What does this mean to physicians? It means they have more time to take care of patients in the hospital before the case manager begins to ask that dreaded question: “When is this patient leaving?” Proper documentation affords physicians one to two days longer to address the patient’s medical issues before their expected length of stay is reached.

IV. Accurate documentation also allows the attending physician to aid the surgeon. The attending must carefully and accurately document in the peri-operative period as to not inadvertently classify an expected outcome as a complication. One example of this is postoperative anemia. This diagnosis can easily be incorrectly classified as a complication. If the attending physician and the surgeon both opine that the anemia is expected, then this should be explicitly documented in the medical record.

Suggestions to Improve Diagnosis Capture

Presently, St. Petersburg General Hospital uses order sets to improve the capture of specific diagnoses. Sepsis order sets have the SIRS criteria with check boxes next to each vital sign and/or lab finding. If the patient meets the SIRS criteria and has a source of infection, then they meet the criteria for sepsis. If the patient has end-organ dysfunction, then they may meet criteria for severe sepsis. These criteria are listed below the SIRS criteria with check boxes next to each abnormal laboratory finding. Download the sample order form.

The order set then lists the criteria for septic shock. These check lists help physicians to comprehensively diagnose, document and order medical therapies, allowing for easy, thorough documentation as well as management. Physicians need to understand, however, that these order sets must be followed up with documentation supporting the diagnosis in the discharge summary.

Correspondingly, St. Petersburg General Hospital uses pneumonia order sets to help physicians correctly diagnose pneumonia without missing complex respiratory diseases. If the physician chooses zosyn, the order set includes the phrase “for suspected gram negative rods.” If the physician chooses vancomycin, then it reads “for suspected MRSA.” Finally, if they choose clindamycin or flagyl, it reads “for suspected aspiration pneumonia.”

Why? Because physicians don’t realize that documenting healthcare-associated pneumonia will code to simple pneumonia unless suspected GNR or MRSA is documented as the causative organism. Also, physicians do not realize that documenting “suspected” or “possible” or “probable” diagnoses in the hospital setting allows those conditions to be coded—as long as the discharge summary documents those diagnoses as well.

Proper coding techniques are not taught to physicians. They have to pick it up themselves in order to document effectively. That’s why CDI efforts are so valuable.

Furthermore, CDI professionals need to educate physicians that laboratory data and radiographic imaging diagnoses are not codeable unless the clinician brings the information into the medical progress note. The radiologist’s impression on an x-ray may read pneumonia, but this diagnosis cannot be coded unless the clinician documents the diagnosis in the medical record. Correspondingly, labs that note low potassium, for example, do not translate to the diagnosis of hypokalemia unless specifically written in the medical record by the clinician.

In summary, physician documentation is critical for MS-DRG capture and assignment of a relative weight as well as an expected length of stay. Physician documentation begins with legible handwriting and moves to accurate diagnosis and effective management of patient care issues. Consider recommending physicians use a pocket CDI card for accurate diagnosis. Download a sample pocket CDI card here.

Convincing physicians to slow down and document effectively isn’t easy. CDI specialists may need to find individual answers for each of their physicians. Some physicians will respond to improvements in their reported quality data, some will respond to improved public reporting, and some may respond to longer length of stay and more time to effectively manage their patient in the hospital. CDI specialists need to listen closely to the doctor for clues as to which approach will lead to change.

All physicians should review their own data on Healthgrades.com. They should monitor their public data, document carefully and thoroughly, and consider reading the book titled, “Who Moved My Cheese?” This little book discusses how to deal with change. Physician scrutiny is here to stay and physicians need to stay ahead of the game.

Editor's Note: This article was written by ACDIS Advisory Board member Timothy N. Brundage, MD, Physician Champion for Kindred Hospital North Florida District in St. Petersburg, Fla. Contact him at
DrBrundage@gmail.com.

Found in Categories:

Education