Back in the 1980s, I would go by medical records every day or two and find, on the front of the charts of my recently discharged patients, a form listing the diagnoses the hospital was billing to Medicare. Before the hospital could submit a patient’s bill, the attending physician was required to review the form and, by signing it, indicate agreement.

The requirement for this signature by the physician went away a long time ago and in my memory is one of the very few examples of reducing a doctor’s paperwork.

For my first few months in practice, I regularly would seek out the people who completed the form and explain they had misunderstood the patient’s clinical situation. “The main issue was a urinary tract infection,” I would say, “but you listed diabetes as the principal diagnosis.”

I don’t ever remember them changing anything based on my feedback. Instead, they explained to me that, for billing purposes, it was legitimate to list diabetes as the principal diagnosis because it had the additional benefit of resulting in a higher payment to the hospital than having “urinary tract infection” listed first.

About 80% of hospitals have formal clinical documentation improvement (CDI) programs to help ensure all clinical conditions are captured and described in the medical record in ways that are valuable for billing and other recordkeeping purposes.

Such was my introduction to the world of documentation and coding for hospital billing purposes and how it can sometimes differ significantly from the way a doctor sees the clinical picture. Things have evolved a lot since then, but the way doctors document medical conditions still has a huge influence on hospital reimbursement.

Hospital CDI Programs

About 80% of hospitals have formal clinical documentation improvement (CDI) programs to help ensure all clinical conditions are captured and described in the medical record in ways that are valuable for billing and other recordkeeping purposes. These programs might lead to you receive queries about your documentation. For example, you might be asked to clarify whether your patient’s pneumonia might be on the basis of aspiration.

Within SHM’s Code-H program, Dr. Richard Pinson, a former ED physician who now works with Houston-based HCQ Consulting, has a good presentation explaining these documentation issues. In it, he makes the point that, in addition to influencing how hospitals are paid, the way various conditions are documented also influences quality ratings.

Table 1. Common documentation issues for hospitalists

Novel Approach

The most common approach to engaging hospitalists in CDI initiatives is to have them attend a presentation on the topic, then put in place documentation specialists who generate queries asking the doctor to clarify diagnoses when it might influence payment, severity of illness determination, etc. Dr. Kenji Asakura, a Seattle hospitalist, and Erik Ordal, MBA, have a company called ClinIntell that analyzes each hospitalist (or other specialty) group’s historical patient mix and trains them on the documentation issues that they see most often. The idea of this focused approach is to make “documentation queries” unnecessary, or at least much less necessary. The benefits of this approach are many, including reducing or eliminating the risk of “leading queries”—that is, queries that seem to encourage the doctor to document a diagnosis because it is an advantage to the hospital rather than a well-considered medical opinion. Leading queries can be regarded as fraudulent and can get a lot of people in trouble.

I asked Kenji and Erik if they could provide me with a list of common documentation issues that most hospitalists need to know more about. Table 1 is what they came up with. I hope it helps you and your practice.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM's "Best Practices in Managing a Hospital Medicine Program" course. Write to him at john.nelson@nelsonflores.com.

Effective Clinical Documentation Can Influence Medicare Reimbursement