Documentation should be concise information, justifying the acuity of an inpatient level of care when appropriate.

Statements that physician documentation needs improvement are always being made. These thoughts come from many levels: executives, nurses, utilization review, quality, clinical documentation integrity specialists (CDISs), physician advisors, and so many others.

For years, I have said that physicians know and understand what they are doing and why, but they don’t translate it into their documentation, for whatever reason. They’re too busy, there are too many rules, etc., etc., etc. I have long taught that they need to “think in ink.” In today’s more electronic world, it may be “think with a keyboard.”

The first question that needs to be addressed on behalf of physicians is why documentation is so important. According to 2011 remarks by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), there are three main reasons, both in patients’ medical records and in claims. They are to protect:

  • The programs
    • Essentially, there needs to be sufficient documentation to ensure that the proper amount is paid – although there are many who feel that the amount of the payment often falls far below what is needed to support the care rendered. In addition, there are those on the payor side who feel that the mark-up from providers is exceedingly high.
  • The patients
    • Accurate documentation can help ensure that patients get the right care at the right time; that’s most important. Recent chart audits/studies done by 3M Canada Health Information Systems staff, in Ontario, reportedly show that more than half of medical records in most hospitals could be improved with more complete and accurate documentation. These gaps are important opportunities for physicians and/or health records coder to improve data capture and documentation, leading to improved quality metrics and data.
  • The provider
    • Documentation needs to be accurate, first of all, in telling the patients’ story, which will lead to better and more efficient delivery of care. Appropriate detailed documentation will lead to accurate coding, and justifying the items and services billed.

A second question that physicians need to be aware of is this: what are the regulatory consequences of inadequate documentation? This may be more of a consequence for the facility charges, but also for the physician, in outpatient claims. This often pertains to the False Claims Act (FCA), 31 U.S.C. §§ 3729 – 3733, which was enacted in 1863 by a Congress concerned that suppliers of goods to the Union Army during the Civil War were defrauding the Army. The FCA has been amended three times since 1986. Over the life of the statute, it has been interpreted on hundreds of occasions by federal courts (which sometimes issue conflicting interpretations of the statute). The FCA is a federal law that makes it a crime for any person or organization to knowingly make a false record or file a false claim regarding any federal healthcare program, which includes any plan or program that provides health benefits, whether directly, through insurance, or otherwise.

There is also another regulation that most physicians are probably not aware of, and that is that they are obliged to document in order to support the care that is ordered and the financial charges for same. This goes along with what the OIG stated, as well as the language of the FCA. Unfortunately, this is not enforced most of the time. But good clinical documentation is part of the core responsibility of every doctor.

In “The Business of Healthcare” blog, in an August 2016 post, it was stated that “clear and concise medical record documentation is critical to providing patients with quality care, ensuring accurate and timely payment for the services furnished, mitigating malpractice risks, and helping healthcare providers evaluate and plan the patient’s treatment and maintain the continuum of care.”

So, how best to “think in ink,” or with a keyboard? Physicians must certainly document beyond commercial, non-physician criteria, typically Interqual or Milliman Care Guidelines, which are used by utilization review (UR). In the Medicare Benefit Policy Manual, Chapter 1, Section 10, there are four bullet points that an admitting physician should utilize in making their determination of an inpatient level of care.

“Factors to be considered when making the decision to admit include such things as:

  • The severity of the signs and symptoms exhibited by the patient;
  • The medical predictability of something adverse happening to the patient;
  • The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and
  • The availability of diagnostic procedures at the time when and at the location where the patient presents.”

Bullet points 1 and 2 essentially help define the acuity of the patient, to justify that inpatient level of care. If that is not defined well, then bullet point 3 just lists care that can be provided at a lesser level, and this is what may be seen many times as the reason for a level-of-care denial.

There are two items from physician documentation that are missing from these UR commercial criteria:

  • Concerns of the physician; and
  • Predictable risks to the patient.

Here are four simple factors that can be used in documentation to establish acuity and help physicians in their decision for level of care:

  • Suspects – What the physician suspects is the reason for the patient presentation and symptoms. In many respects, it is similar to a differential diagnosis list, but there should be clinical support for any diagnosis listed.
  • Concerns – Does the physician have high or low levels of concern for what can be an adverse event, based on how the patient presents and the condition in which they present?
  • Predictable Risk – How predictable is the risk of adverse events from the patient presentation? Physicians know this from their experience, literature, their education, conferences, etc.
  • Intent for Treatment – How will they be treating the patient, including an expectation for two midnights?

In order to help decide what initial level of care should be ordered, when the physician has a high level of concern for highly predictable events, they tend to order inpatient care. When there is a low level of concern for low predictable events, they tend to order observation. This is not a foolproof process, but it helps, since many times physicians claim that they know how to take care of patients, but have a hard time transitioning that knowledge into a level-of-care decision.

This does not require a long statement, but concise, accurate information, telling the patient’s story, justifying the acuity of an inpatient level of care when appropriate.

Remember: it’s time to “think in ink!”