Its a classic Catch-22. Hospital coding specialists must rely only on doctors notes to determine if a medical condition was present at the time a Medicare patient is admitted to the hospital. But it is often nursesnot doctorswho document that type of information.
The present on admission, or POA, designation was rolled out for Medicare claims, beginning in October 2007. The rule specifies that every diagnosis code listed on a bill must be accompanied by a POA code.
Hospital managers have cause to be concerned about the quality of POA documentation. Beginning Oct. 1, 2008, Medicare plans to exclude from calculations of payment rates certain preventable conditionssuch as catheter-associated infections or bedsoresif those conditions were acquired at the hospital.
Its a documentation headache for hospitals. Much of the information is gained from nurses, and the CMS coders are not allowed to use that information, says Darrell Campbell, chief of clinical affairs at the University of Michigan Health System, Ann Arbor. For example, Coders can only make a decision on the presence of a catheter at the time of admission based on physicians notes. Physicians are not good at documenting that, says Campbell. Likewise, nurses will determine if a patient had bedsores when they came in from a nursing home. Doctors frequently dont write that down.
The rule will put a new burden on physicians to be very crisp and clear about what they are observing. They also have to know what these hospital-acquired conditions are and what they are looking for when the patient presents to the hospital, says Nancy Foster, vice president of quality and patient-safety policy at the American Hospital Association. For example, Foster says, If the patient is coming in to us from a trauma, it would be important to record what the injuries are. Otherwise, if something later emerges on the chart as a sprained wrist, you dont know if that was caused by the original injury or because the patient fell out of bed.
Thats why managers at 405-bed Memorial Health Care System in Chattanooga, Tenn., believe that concurrent coding is the best way to address the POA documentation issue.
Concurrent coding is a process in which employees trained in coding work directly on the inpatient units, coding care as it happens. Memorial Health Care switched in the 1990s to concurrent coding from retrospective codinga process in which coding occurs after the patient is discharged from the hospital. In 2005, Memorial Health Care also added documentation specialistsexperienced nurses with specialized trainingto inpatient units. The documentation specialists work with both coding specialists and physicians. They review charts from a clinical perspective and obtain from physicians missing documentation or clarification of information in progress notes. They also respond to requests from coding specialists for more information.
To find out how well the concurrent process was working to identify conditions that are present on admission, Melissa Roden, vice president of quality at Memorial Health Care, spent several hours analyzing patient records.
The result of Rodens audit: Three out of 150 records included the U code, which means documentation was insufficient to determine whether a condition was present at the time of inpatient admission. In all other cases, the documentation was good enough to allow coding specialists to enter a Y for yes or N for no.
Kettering (Ohio) Medical Centerthe 145-bed flagship facility of three-hospital Kettering Health Networkcreated a form that documentation specialists use to request clarification from physicians about whether a medical condition was present at the time of admission. As is the case at Memorial, Ketterings documentation specialists are assigned to inpatient units; however, coding specialists do not work on the unit.
Executives at Kettering expect the extra responsibility of documenting whether a condition was POA to fall heavily on staff in the emergency department because it is the first stop in a hospital stay for many patients.
To help emergency department physicians cope, Kettering added a documentation specialist for a six-week trial period, beginning in late January 2008.
Kettering managers then monitored the financial impact of the documentation specialist for an eight-day period. They discovered that the documentation specialist had uncovered three cases of urinary tract infections and two cases of bedsoresall of which were clearly present on admission but lacking proper documentation. If those cases had been excluded from Medicares payment calculations, Kettering would have lost $10,900 in reimbursement, according to Teri Sholder, manager for clinical documentation specialists at Kettering.
Despite the financial impact, Kettering hasnt yet made the documentation specialist position in the emergency department permanent. Managers want to find out if they can garner similar financial results simply by teaching nurses who already work in the emergency department about how to document for POA conditions. The nurses can then work with physicians to produce the proper documentation.
Says Sholder, We are still in the assessment stage.