10 Tips To Help Your Physicians Adjust to MS DRGs


Vol. 18 •Issue 8 • Page 20
10 Tips To Help Your Physicians Adjust to MS DRGs

Part 2: The second in a series of valuable steps to inform, educate and ultimately partner with physicians in the new era of MS DRGs.

While all revenue cycle stakeholders are involved in ensuring complete and accurate reimbursement, it is often the HIM department and clinical coding staff that carry the heaviest load. What most health care executives haven’t understood until now is that there is a direct cause and effect relationship between clinical documentation and clinical coding. Thankfully, they are about to learn!

Clinical documentation integrity and clinical documentation improvement (CDI) programs are on the rise and with them, a shared responsibility for fiscal success under MS DRGs. There is an Association of Clinical Documentation Improvement Specialists. Many vendors offer CDI consulting services, and some forward-thinking physicians have started peer-to-peer educational programs. Everyone is working together to educate, inform and improve clinical documentation. And “everyone” must include physicians.

In our first article, we discussed six steps for HIM directors to help prepare their physicians under MS DRGs. This article provides four more practical tips to get your physicians involved and on board!

Ali Baba and MS DRGs

Like the famous story of Ali Baba and the 40 thieves, health care executives and some HIM professionals suggest we only need to teach physicians the specific words and phrases they need to open the magic fortune of MS DRGs. Unfortunately, it’s a little more complicated than that!

According to Dr. Norman Ward, medical director of case management at Fletcher Allen Healthcare, “you can train physicians to be aware of the magic words for coding under MS DRGs, but you need to provide them with a solid rationale and data to support your position.” Dr. Ward believes that physicians will continue to do their jobs and deliver care as they have always done, regardless of how Medicare calculates reimbursement. To effectively teach the “magic words,” HIM professionals should educate each specialty on the words and phrases that impact coding within their unique patient mix. From there, Dr. Ward suggests using case studies and statistics such as those available from the various quality data reporting organizations to get their attention and prove your point. And as two decades of physician queries demonstrate, proving your point with the medical staff is not an easy task!

Effective Physician Queries Focus on Respect

The physician query process has been around since the introduction of prospective payment in the 1980s. Written by coders, queries obtain clarification and additional information directly from the physician and most often result in improved clinical coding. Some are highly successful and some are not.

“With the implementation of MS DRGs, our physician queries have dramatically increased,” mentioned Dr. Ward. But at the same time, our queries have proven to justify the appropriate reimbursement. Indeed, more specific documentation is needed with MS DRGs and often this results in a physician query.

The most important point to consider when developing your query process is physician involvement. Don’t construct your process without garnering physician input and acceptance. HIM professionals must be respectful of physicians’ time and intelligence. While they weren’t trained in the fine nuances of coding, they are busy saving lives and curing diseases every day. The query process must respect their schedules and job priorities.

Another suggestion is to establish a concurrent query process whereby coders become active team members on the nursing unit. By moving the query process to a concurrent vs. retrospective step, clinical documentation can be enhanced simultaneously with patient care—improving clinical communication and specificity for accurate coding. Over time, an effective CDI program would reduce the number and need for concurrent queries.

Whether your query process is concurrent or retrospective, it is important to track an individual physician’s performance, response to queries, complication and co-morbidity (CC) rates and case-mix index. By carefully establishing, monitoring and reporting these metrics, HIM professionals will have the data they need to evaluate the success of their CDI program.

  • Checklist of all queries and cases. Track responses.
  • Identify most common queries and develop standard templates.
  • Keep compliant: clarify but don’t lead the physician.
  • Have a senior coder or manager review queries for appropriate and effectively written queries before sending.
  • Use proven tools and forms, if possible.
  • Track each physician’s CC and MCC capture rates and case-mix index.
  • Have a physician champion in place for support.

Use All Resources

Clinical coders know that there’s much more to a patient’s story than just his or her discharge summary. But too often coders and other CDI specialists rely too heavily on the discharge summary and other transcribed reports to the exclusion of other handwritten or ancillary information when reviewing a case. Coders must be trained to look at every document within the patient record before submitting a physician query.

According to Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, in his recent article published in CDI Strategies, Jan. 10, 200

  • , there is a proven plan of attack that all coders should follow before bothering a physician. Steps include looking at the ambulance and emergency department records, patient history and consultant notes, physician orders, medication administration records, all ancillary reports and progress notes. He also advises that coders look for diagnosis and conditions the physician is trying to rule out or what clinical path he or she is pursuing. These subtle nuances are the foundation for a respectful query.

    Beyond the medical record, coders should look to physician assistants, nursing supervisors, quality assurance teams and utilization review professionals for guidance on specific diagnosis, procedures and cases. There are numerous resources available, including coverage guidelines from payers, clinical practice guidelines, quality measures, medical specialty societies and of course, Internet searches. In addition, many organizations, including the American Health Information Management Association (AHIMA) and American Academy for Professional Coders (AAPC) offer MS DRG webinars. Lean on these resources before you lean on your physicians!

    Keep Up With Medicine

    Our final suggestion is to keep up with medicine. New diagnoses, procedures, medications and exams are announced daily. Your organization may announce a new patient service or employ a new physician specialist. Work with your medical staff department and physician department heads to keep abreast of changes.

    We suggest hospitalists or other employed physician groups hold a monthly coding workshop to review new clinical topics. During the workshop, coders can discuss the various codes involved and what kind of clinical documentation is required.

    Another suggestion is to give your coders access to important medical journal articles, the medical staff library, physician in-service offerings and outside educational workshops. Establish an educational liaison with each medical staff department.

    Coding is a Team Sport

    Many organizations are struggling under MS DRGs and many more will be at risk once Medicare fully transitions to the new payment system on Oct. 1, 2008. HIM professionals can help their coders, physicians and organizations succeed under MS DRGs through a teamwork approach that includes physicians and a strong CDI program. And to get your physicians on board, HIM professionals should remember a few basic truths about their clinical peers:

    • Most physicians were never taught the importance of clinical documentation.
    • Communication is not a core competency for most medical staff.
    • MS DRGs are more about quality and refinement vs. reimbursement.
    • Physician quality scores are created and driven directly from codes.

    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 10 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.

    Four Common Physician Queries

    • Heart failure: acute vs. chronic vs. both and diastolic vs. systolic vs. both.
    • Acute and chronic respiratory failure
    • Various stages of chronic kidney disease
    • Transfusion for acute blood loss anemia and recording an indication for therapy

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