Improving Physician Documentation

Improving Physician Documentation

Page 18

Cover Story

Improving Physician Documentation


Clinical documentation is continually coming to the forefront, in light of health care compliance initiatives and greater scrutiny by the Office of the Inspector General (OIG). Throughout the health information management (HIM) profession, you will find that “documentation” is felt to be at the center of many DRG compliance problems. In particular, physician documentation is clearly less detailed and specific than we need it to be for compliance, coding and reimbursement purposes.

Without complete, accurate, thorough and specific clinical documentation from the physician, coding can never improve. And who are the experts that know what’s needed for complete documentation? It’s you–HIM coding professionals.

Now, let’s not just talk about coding for DRGs; let’s also discuss and think about the effect that coding is having upon severity, acuity and patient outcomes. Take this concept one step further, and let’s think about the impact coding plays in “hospital report cards.” In the future, what role will coding play on physician report cards?

Improving physician documentation through a concurrent documentation review process can have a positive effect on the clinicians, physicians and data quality. Here’s a look at a specific project that addresses this.

We began a project called “Concurrent Documentation Improvement,” with educational in-services to case management and coding staff that outlined the problems that exist today with unspecific and unclear physician documentation.

The in-service started with a background look at health care compliance and the OIG audit results of 1997. This included information on health care claims from 1996, which were audited to identify potential fraud and abuse. The results were as follows:

  • 48 % Insufficient/no documentation
  • 36 % Do not meet “Medical Necessity”
  • 8 % Coding errors
  • 5.2 % Noncovered or Unallowable service
  • 2.6 % Other

The audit also identified the following health care settings to be primarily responsible:

  1. 22.5 % Inpatient
  2. 21.6 % Physician Office
  3. 15.7 % Home Health
  4. 12.1 % Outpatient
  5. 10.4 % Skilled Nursing Facility
  6. 5.7 % Laboratory
  7. 11.6 % Other

Coders most often express the key problem related to the coding process to be poor or unspecific physician documentation or the lack of documentation all together. This in turn creates coding and DRG assignment problems. Clinicians don’t understand the coding methodology and specific guidelines surrounding documentation and assigning ICD-9-CM codes. Within HIM departments, we continually hear comments being made about the problems with documentation, but nothing is being done about it. Taking action and attempting to make a difference is the beginning–one step at a time. That first step may include the implementation of a concurrent documentation review program, which is not to be confused with “concurrent coding.”

With this said, additional information was provided to case managers and coding staff on our inpatient prospective payment system (PPS) to better understand that clinical documentation is used to validate resource consumption for the treatment and care of patients.

This included the following information:

  • A brief history of Medicare’s inpatient PPS
  • DRG methodology and MDCs
  • Details on the calculation of Case Mix Index (CMI)
  • The education of other clinicians, including respiratory therapy, dietary, nurse managers, utilization review, etc.
  • Specific DRG documentation issues and examples
  • Severity and acuity information; and
  • Problematic documentation and target DRGs.

Our program’s goals and objectives were to:

  • Increase clinician knowledge and understanding of the linkage between clinical documentation, coding and the severity and acuity of the patient mix
  • Enhance clinical documentation quality through education and physician queries
  • Increase the visibility of the HIM coding professional and demonstrate their expertise
  • Validate the theory that more specific clinical documentation will produce a more exact CMI, improve data quality and create a partnership with HIM and physicians/clinicians
  • Present results, and justify resource and HIM utilization; and
  • Provide statistical data, which will assist in proving patient care and outcomes.

Our process with case management was to:

  • Educate them about severity and acuity through in-service on CMI and the documentation linkage
  • Build partnerships
  • Work with case management and the nursing staff to team together on a daily basis
  • Initiate in-services to outline the issues and present solutions; and
  • Utilize the case managers’ knowledge and involvement with patients on a daily basis.

We published information about this project (via memo) and gave it to the medical staff. We also sent all nursing floors a memo outlining the project and who would be reviewing the medical records concurrently (on the floors).

Concurrent documentation review involves having an experienced inpatient coder review patient records and utilize a worksheet to gather data and information. (See Table 1 on our Web site at under “Im-proving Data Quality” for an example of the worksheet.) The medical record is reviewed while the patient was in the hospital, on the floor. This is performed on a daily basis, each morning. Using the worksheet, the coder gathered specific data and monitored those with insufficient or unspecific documentation patterns within the diagnoses. When documentation clarification is obtained in the medical record, the worksheet is used to indicate that for tracking purposes.

Communication and partnership was established with the coding, case management and ancillary staff as needed, as this is a key area for project success. Because these clinicians are routinely communicating the patient’s condition to the physician, they are the ideal link to documentation improvement. The coding reviewer would scan dictated reports, nursing notes, lab, radiology, ancillary notes, progress notes, etc. and then utilize a “physician query form” to seek clarification if clinically appropriate.

Information/data was gathered and logged on the worksheet. If an unspecific diabetes type was documented, for example, a “Diabetes Query” was placed on the chart (in front of the most recent progress note) and the case manager was notified and thus, the physician was asked to document the specific type and/or complications or manifestations. If a medical record indicated that a patient was given a blood transfusion and the documentation didn’t indicate the diagnosis/indication for this treatment, the case manager would assist in querying the physician about this or the nurse who takes the order for the transfusion can obtain the specific diagnosis.

To discover what specific type of anemia a patient had, a “physician query” for “Anemia” was utilized and placed on the chart, next to the most recent progress note. (See Table 2 on our Web site at www The case mana-ger’s role was to follow-up with the physician and also initiate “physician queries” when appropriate. Other clinicians were also encouraged to become involved in the project and review medical record documentation.

Other standardized physician documentation queries have been developed to address the need for greater specificity or clarification in the areas of sepsis vs. urosepsis, pneumonia, chest pain, angina, cardiac arrhythmia, diabetes, dietary diagnosis, medication and diagnosis, and CVA/stroke.

At the end of the month, the coding/HIM project coordinator tallied the review worksheets. Those cases in which a query was applied to the chart (progress notes, orders, etc.) were totaled. The number of cases in which a response was received from the physician (via the clinical documentation) and the total number of cases were obtained. Calculations were made of the number of records in which a change in the documentation was made and resulted in a more specific diagnosis or condition, and then those that impacted the DRG assignment. Also, those cases in which the severity/acuity (using APR-DRGs) was changed was calculated. The results of our concurrent documentation review indicated the following for the first two months:

First month of Review: 51 charts reviewed

  • Additional documentation clarification was needed in 13 cases.
  • Physicians responded to the documentation query in eight cases.
  • The severity and acuity level was impacted (increased) in four cases.

Case Mix Index (Resource Consumption value)

4 cases CMI = 1.1108 (original documentation)

Changed to 1.6258 (revised documentation)

Second month of review: 81 charts reviewed

  • Additional documentation clarification was needed in 12 cases.
  • Physicians responded to the documentation query in four cases.
  • The severity and acuity level was impacted (increased) in two cases.

Case Mix Index (Resource Consumption value)

2 cases CMI = 0.9894 (original documentation)

Changed to 1.5527 (revised documentation)

We had the coder spend two hours on the floor each morning (Monday through Friday), and for this project we selected one floor/unit as the beta site. Usually the coder could review about 17 to 20 charts in the two-hour period. We also conducted a financial impact and cost justification analysis, which proved that concurrent documentation review was financially a success.

Our conclusion and results indicated that we could target specific documentation improvement areas in obtaining the specific type of pneumonia when known by the physician. This was especially true for “aspiration pneumonia” diagnosis, by using physician queries for clarification and greater specificity. We also identified patients who were given blood transfusions, but there wasn’t any clinical documentation of the indication or diagnosis for the transfusion. Through the physician query on a concurrent basis, diagnostic clarification was obtained in the progress notes. We also identified that dietary staff was being asked to evaluate patients, and the nutritional diagnoses were often in the dietary documentation but not in the physician’s notes. Through concurrent physician queries, with assistance from the dietary staff, we were able to obtain nutritional diagnoses (in particular malnutrition) and provide medical necessity for the treatment being given by clinicians.

We were able to track physician patterns and narrow ongoing documentation problems to specific physician groups. Finally, we were able to find nursing verbal orders for medication that on a rare occasion would contain the indication or diagnosis in the order. By obtaining diagnostic clarification as part of the physician order language, this provided another place in the medical record with specific physician documentation. For example:

MD order states = “Colace 250 mg.po/q day for constipation”

“Ativan 0.5 mg po. prn for anxiety/agitation.”

“Lasix now for CHF”

(Identifying the clinical indication or diagnosis in the order can decrease medication errors some researchers have found).

Using physician queries on a concurrent basis involves the physicians who are currently treating their patients, rather than contacting the physicians sometimes two weeks after discharge and asking them to come back and document additional clarification. Coding staff may even hold the case until the physician has provided clarification, which has a negative impact on AR. Multiple calls to the physician offices were being made and this was decreased with concurrent documentation review. Because the case management staff is already concurrently working with the patient case on a daily basis, they have a thorough understanding of the patient’s conditions and treatment.

Specific inservices with the physician groups were done before the project and after, sharing information about the issue of documentation. Several physicians felt that they “just need to know the rules” about documentation and they will write it down. This was in addition to several one-on-one discussions with physicians.

Information about complete and thorough documentation in physician dictated reports was also addressed via the posting of a single page sheet that provided details on the elements needed for complete history and physical reports, operative reports, consultations and discharge summaries. For the specific elements we indicated, see ADVANCE’s Web site at

These sheets were printed on colored paper, laminated and posted throughout the hospital, in any area where a physician dictates or works on charts. We were able to demonstrate an improvement in clinical data quality, and we saw a more accurate reflection of the acuity and severity of our patient population. Coding specificity was increased through concurrent documentation improvement. The CMI also demonstrated an improvement. The coding staff expressed a new understanding of severity and acuity data that they had not had before, as the emphasis had always being placed on “getting the DRG.”

I encourage HIM professionals to investigate developing a process for concurrent documentation review as part of their overall compliance activities. There is a great need, so let’s rally together and be proactive on improving clinical documentation. Collaboration with a shared vision can make a difference.

Gloryanne Bryant is the director of systemwide coding/HIM compliance at Catholic Healthcare West, San Francisco, CA. For a complete copy of the PowerPoint presentation to Case Management and Coding Staff, you can contact Gloryanne at [email protected].

Starting Your Own Concurrent Documentation Improvement Project

Things you should take into consideration if planning a concurrent documentation improvement project include:

  • Coordinate the objectives of the project with others in the facility
  • Present and discuss the project findings and results with the chief of staff, administration, nursing, etc.
  • Continue to educate nursing and leadership staff
  • Create a multidisciplinary team approach
  • Prepare monthly statistics
  • Give feedback to physicians via newsletter or specialty meetings
  • Monitor and track your DRGs, CMI and documentation issues on a monthly basis.