These denials can be overturned with time and the right expertise. The goal however, is to prevent the denial in the first place. The length of stay does not have to become a loss with appropriate clinical documentation.
Auditors, with their checklists of discharge criteria, are looking for documented evidence of the severity of the patient’s illness (SOI) and the intensity of services (IOS) required by the patient. (Auditors often begin and end their review with the physician documentation.)
If auditors can’t identify this information, written legibly and in terms they can understand, they are likely to determine that the patient “could have received further treatment at a lower level of care.” As a result, the last few days of care are denied.
As most of us know, a key part of preventing denials lies in the hands of our physicians’ documentation. But asking busy physicians to either “document better” or worse, impose penalties for “poor documentation” is likely to bring on a chorus of “Well, tell me what you want me to write!!”
As a physician who has appealed hundreds of these denials, and who has also written hundreds of progress notes, I’m convinced that many LOS (length of stay) denials can be prevented.
What if there were some simple rules for LOS notes?
Consider this scenario adapted from actual cases referred to us:
Mrs. Gray, a 65 year-old obese diabetic former smoker, had a total knee replacement. She has a postoperative fever and doesn’t feel well. Her orthopedist writes this plan: “Observe over weekend.”
But why does she require observation? Does this plan mean that she needs the Observation level of care? How sick is she? What services does she require? In other words, writing “Observe over weekend” does nothing to support the physician’s reasons for this plan.
What if the physician had written this best practice progress note?
“Assessment and Plan: Postoperative fever: possible sources of fever include wound infection, sepsis, urinary tract infection, or pneumonia. Get chest x-ray, blood cultures x 2, urine culture. Will consult Infectious Diseases for advice on further management. Reassess the patient in 24 hours and consider wound culture. Increase IV fluid rate to 125cc/hr.”
This note incorporates a few simple rules that physicians can follow to improve the documentation of their patient care that will result in fewer denials:
1. Write not only for other physicians, but also for utilization reviewers, coders, and auditors. The days of utilizing the medical record to communicate only with other caregivers are over.
2. Document SOI (severity of illness) and IOS (intensity of services): What makes your patient so sick she must remain hospitalized? What services can be given only at this level of care?
3. Treat weekend days just like any others. Reassess patients for potential discharge on an ongoing, daily basis.
4. State why your plan is appropriate – remember the key word BECAUSE, even if you don’t specifically write it. “The patient needs acute inpatient care because the source of her fever is unclear and needs further evaluation with multiple studies and consultations.”
5. Include detailed data to support your decision. Medical decision-making is complex, so write down all the facts that go into your plan.
6. Avoid copying-and-pasting boilerplate statements. Repeatedly using the same justification for continued LOS weakens your arguments.
7. Begin discharge planning as soon as possible.
These simple rules can help you keep your LOS from becoming a LOSS.
About the Author
Cynthia M. Lipsitz, MD, MPH, is a Senior Medical Reviewer with Washington and West, LLC, an appeals and denials management company. In this capacity she maintains familiarity with current standards of medical care, Medicare and private payer hospitalization criteria, and coverage policies. Dr. Lipsitz has reviewed records and observed documentation patterns from a variety of hospitals across the country and has a heightened understanding of issues that lead to denials. With over 25 years of experience in ambulatory and hospital medicine, public health administration and health promotion software development, she brings an understanding of the realities of medical practice and administration to the field of denials management.
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