Vol. 18 •Issue 3 • Page 24
10 Tips To Help Your Physicians Adjust to MS-DRGs
Part 1: Use these valuable steps to inform, educate and ultimately partner with physicians in the new era of MS-DRGs.
TThe preparation was long and arduous, but it has paid off. Revenue cycle managers are on board, coders have prepared and chief financial officers understand the impact on revenue and quality reporting. And now, finally, what we’ve all been waiting for: the most important changes in the Medicare inpatient prospective payment system are here.
Do your physicians understand the importance of their own clinical documentation? Do they know that words, phrases and terms used every day in the patient’s medical record are cornerstones for fiscal health and national quality health grades?
In our experience, the answer is probably “no.” At best case, the answer is “maybe.”
A Fresh Approach
Physicians were never taught that clinical documentation was important, much less pivotal, to a health care organization’s long-term viability. To get physicians on board and improve their clinical documentation practices, you need a new, fresh approach. HIM departments have struggled with physician documentation in the past. Now that more specific documentation is needed, your job is even tougher!
The 10 tips included in this article and in Part II of this series, scheduled for April, provide valuable practice steps every HIM department can take to inform, educate and ultimately partner with physicians in the new era of MS-DRGs.
Show Them the Big Picture
The first step is to take a few minutes to tell your physicians the whole story; show them the big picture. Physicians are scientists; they need to understand the bigger context from which something evolves. What has prospective payment been doing over the past 25 years, and what is the government trying to accomplish with this change? The answer is more accurate reimbursement and better data for quality health grade reporting.
From a technology perspective, remind them that when DRGs first came to us in 1982, personal computers used floppy discs, had green screens and held only 2 megabytes of memory. Technology has come a long way, and it makes sense that Medicare, as the largest payer in the United States, should revisit the original 355 base DRGs.
Codes and Quality: Explain the Relationship
Remind physicians that correct coding is not only about money but also about quality health grades that are posted on the Internet. For the general public, the availability of quality scores and grades for providers and health care organizations are a benefit. Consumers take no offense to the information and often use health grades to choose a provider.
Physicians, however, are offended by health grade reporting. Quality scores are a direct reflection of physician and hospital performance. And because physicians are a competitive group in general, they are keenly aware of how they rank against peers. Take the time to explain how quality scores are really driven straight from ICD-9-CM codes and their associated DRGs.
Remind your physicians that MS-DRGs took everything that was unspecified or somehow otherwise not stratified along the spectrum of disease and defaulted it to the low risk category. More specific documentation results in more specific codes, which push patients up the spectrum of disease and result in an accurate reflection of physician performance.
To reinforce the message, present a single case that was coded with and without specification. Show your physicians the associated clinical documentation in both cases and how it was used by the coders. From there, explain how these cases would havebeen selected for quality reporting and share any health grade results or statistics from your organization’s Web site related tothis example. This exercise can truly be a “light bulb moment” for your physicians.
Communication as a Core Competency
Physicians were never taught to communicate effectively with non-physician readers of the medical record. In medical school, the only purpose for written communication was to give the next physician information to care for the patient. However, with MS-DRGs, physicians must be better communicators to survive.
The good news is that organizations like Midwest Healthcare Coding are working with medical schools around the country to develop communication curriculum. Today’s medical students are learning the importance of communication. But until these new physicians are walking the halls of our institutions, HIM departments can lead the charge.
Remind your physicians that many non-physician readers of the medical record have an interest in their documentation. Not only coders, but billers, case managers, auditors and attorneys will be reading what they write or dictate. Be cautious that physicians may hear this message as a request to perform someone else’s job. This is not the case! Others will do their own jobs. But non-physician readers can only be effective when physician documentation is specific, clear and complete.
According to Dr. Norman Ward, medical director case management at Fletcher Allen Health Care, “incomplete communication in the medical record only leads to more physician queries, more paperwork and increased frustration between coder and clinician.” This is a reality that must be stressed. Use a specific case example of incomplete physician documentation alongside the coder’s query log to drive home the point. You may even consider attaching time estimates to each step for the case to demonstrate how much time is wasted when documentation is vague.
Find a Physician Champion
To improve clinical documentation and succeed under MS-DRGs, hospitals must find and cultivate a physician champion, or team of champions. This may be your medical director or department chiefs. Choose someone with solid physician relationships, an understanding of prospective payment and good people skills. This physician should work with HIM and the clinical documentation improvement or integrity team to:
“In my role as the medical director, I consult with the coders and teach them how to query physicians appropriately,” mentioned Dr. Ward. The goal is not to insult the physician but to elicit their help as part of your team.
Demonstrate Your Encoder
Sometimes a picture speaks a thousand words. When trying to explain the coding process to physicians, a brief demonstration of your encoder can open eyes and minds. Dr. Ward demonstrates the organization’s 3M encoder at specialty group staff meetings with amazing results.
“By seeing how the encoder works, physicians realize that coders have to search every page of a chart,” explained Dr. Ward. It also teaches the physician exactly how specific codes impact the MS-DRG. As an added benefit, the demonstration helps physicians understand the importance of clinical documentation for present on admission (POA) requirements. “The encoder application won’t complete a case unless POA codes are entered,” he concluded.
Physicians respond to real case examples, statistical feedback and clinical data. In demonstrating the encoder, Dr. Ward uses a specific case to demonstrate the difference additional diagnoses and specificity make. For example, he demonstrates the coding of a simple hip fracture vs. a hip fracture with congestive heart failure (CHF) and the same fracture with CHF and a decubitus ulcer. “Not only does the reimbursement increase up to 50 percent, but the quality index changes right in front of their eyes,” he noted.
A Physician’s Perspective
At the end of the day, physicians are not going to care for patients any differently than they did a year ago just because Medicare changed DRGs. And likewise, HIM departments have always worked toward more complete and accurate clinical documentation.
The difference with MS-DRGs is the importance of codes has gone well beyond financial reimbursement for the provider organization and is starting to directly impact the physician’s quality scores. When we can move the focus from reimbursement to quality and refinement to better reflect physician performance, we can redirect our efforts to achieve success.
Look for Part II of this series and explore the final four tips on helping physicians adjust to MS-DRGs in the April 21 issue.
Donna Didier is the director of auditing and educational services at HealthPort, formerly SDS, where she helps guide HIM departments through clinical documentation and coding compliance improvement programs. Dr. William W. Walker is a board certified internist practicing in the intensive care unit setting. He founded Midwest Healthcare Coding to provide communication support and practical education for physicians, coders and administrators regarding documentation.
Top Ten Tips
1. Show them the big picture of prospective payment.
2. Explain the relationship between codes and quality scores. Use statistical feedback.
3. Teach the importance of communication.
4. Find physician champions.
5. Demonstrate your encoder using real case examples.
6. Identify fundamental disconnects between coder and physician.
7. Train physicians on the “magic words” for coding.
8. Develop query process with physician input.
9. Use all available resources before query.
10. Research new services and procedures.
