Documentation is the key to getting paid

Make sure record is complete

As the Medicare Inpatient Prospective Payment System (IPPS) final rule goes into effect, the biggest struggle for hospitals, physicians, and case managers will be providing thorough documentation in order to ensure that hospitals receive their proper reimbursement, says Ralph Wuebker, MD, MBA, chief medical officer for Executive Health Resources, a Newtown Square, PA, healthcare consulting firm.

The final rule requires physicians to state how many days they expect the patient to be in the hospital, the rationale for in-hospital care and the plan of treatment, Wuebker says.

"The documentation doesn’t have to be an elaborate four-page history and physical. Frequently, the necessary documentation can be accomplished with just three or four sentences. Unfortunately, we see a lot of documentation that is just one or two words, and that will not be sufficient. Improving that kind of documentation is going to be the challenge for case managers," he says.

At best, physicians typically include patient history and general findings in the documentation but rarely write out a plan of care and never include the expected length of stay, adds Linda Sallee, MS, RN, CMAC, ACM, IQCI, director, for Huron Healthcare with headquarters in Chicago. "In some cases, the information needed for medical necessity is in the physician’s office and not the chart. Case managers are going to have to work closely with physicians to make sure the documentation reflects that patients need care in the hospital, rather than being treated and sent home," she says.

For instance, physicians have sometimes admitted frail elderly dementia patients for three days so they qualify for a nursing home stay. "Some of these patients don’t need inpatient treatment or even observation services. They need to be treated as outpatients and sent home," she says.

Under the final rule, physician documentation is expected to include what is wrong with the patients that indicate they need care in the hospital, including severity of illness and intensity of service. It must include the plan of care and the expected length of stay.

"This is a huge turn of events for physicians. Some write very little in the chart. This is why case managers need to see every patient in person in addition to reviewing the chart and make sure that the patient’s actual condition and services received match what is in the chart," she says.

In order for the hospital to bill Medicare, the documentation has to certify that the patients need to be in the hospital, Sallee points out. Physicians need to make a list of the reasons patients require care in the hospital or write the reasons out as a narrative, she adds.

Case managers should see every patient in person within 24 hours of admission and make sure the patient’s condition and treatment are documented in the chart, then call the physician if what they see isn’t reflected in the chart, she suggests. "Physicians must be very thorough and document the condition completely. Case managers can’t simply call a physician and say a patient doesn’t meet criteria. They must ensure that the physician is very specific about the patient’s condition and be sure that it is accurately reflected in the chart, in turn, to justify and explain the inpatient stay," she says.

As you work with physicians, help them to document the case as accurately as possible in accordance with the final rule, Wuebker says. Ask them to include their medical rationale and not just the treatment plan. Adding this piece will ensure documentation is clear if the case does get selected for audit. In addition, make sure there is an order for admission. Ask the physicians to "think in ink," he says.

"Asking the physicians to get the expected length of stay correct up front is challenging," Wuebker says. Instead of asking physicians if they expect patients to be in the hospital over two midnights, ask them if they expect that the patients will go home the next day. If they think that the patient will go home in the morning, the patient should be an outpatient receiving observation services. If not, the patient should be admitted as an inpatient. "This type of question translates the regulations into guidelines physicians can use and understand. And getting the physicians’ cooperation begins with understanding," he adds. 