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Whose documentation counts?

From the November ACP Hospitalist, copyright © 2011 by the American College of Physicians

By Richard D. Pinson, MD, FACP

Sidebars: Clarification Ask Dr. Pinson

Understanding whose documentation can actually be used for inpatient coding purposes is often a source of confusion and controversy. Misunderstandings can result in noncompliance or lost revenue for the hospital.

CMS official coding guidelines permit only documentation by a “healthcare provider” who is further defined as “any qualified healthcare practitioner who is legally accountable for establishing the patient's diagnosis.” This implies licensure or certification by a state agency and credentialing by the practitioner's organization (e.g., hospital medical staff). These requirements may vary state by state.

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This definition of a health care provider may include physicians, osteopathic physicians, podiatrists, chiropractors, psychologists, advanced practice providers (such as nurse practitioners, physician assistants, nurse anesthetists), and residents and interns who meet the legal requirements. Medical students, nurses, nutritionists, physical therapists, respiratory therapists, social workers, and rehabilitation or occupational therapists are not included.

Two exceptions allow documentation of a condition by someone other than the health care provider: BMI and the stage of pressure ulcers. However, the health care provider must still document the presence and location of pressure ulcers, as well as a clinically relevant condition associated with an abnormal BMI.

In addition, for inpatient coding, the health care provider must be “directly involved” in the care of a patient. At a minimum, this requires speaking with and/or touching the patient while providing some sort of care. Therefore, medical reports such as imaging studies, laboratory or pathology reports, EKGs, echocardiograms, and exercise stress testing are not sufficient documentation. For inpatient coding, such reports must be specifically “interpreted” in the medical record by one of the patient's health care providers to serve as source documentation. Outpatient rules are somewhat different with respect to medical reports. If a health care provider performs an invasive procedure (e.g., interventional radiology or percutaneous cardiovascular studies), a procedural report is required and may be used as source documentation for coding.

Coders are instructed to use the entire medical record for a particular inpatient admission as the source for documentation; information contained only in a previous admission record is not used. CMS regulations specifically state, “Documentation is not limited to the face sheet, discharge summary, progress notes, history and physical, or other report designed to capture diagnostic information.” Some coders (and auditors) hold the mistaken impression that the discharge summary is definitive, or that information not included there cannot be used for code assignment.

Coders can and must use any and all source documentation contained in the medical record from all health care providers so long as it is clear, consistent and not conflicting. No health care provider's documentation takes precedence over another's; any health care provider's documentation is considered equally valid. If the patient is admitted from the emergency department, the emergency record becomes part of the inpatient record and is used for inpatient coding. Whenever there is conflicting information in the record, the attending physician is responsible for clarification and a final determination.

Richard Pinson, MD, FACP, is a certified coding specialist and co-founder of HCQ Consulting in Houston. This content is adapted with permission from HCQ Consulting.

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Clarification

Your piece in the August issue (“Placing priority on pressure ulcers”) states that the ischial tuberosity is the lateral hip. This is not true. We sit on our ischial tuberosities. The lateral hip ulcers are typically caused by the femoral trochanter and less commonly the iliac crest or posterior spine.

Pressure ulcers are formed by the compression of soft tissue between a bone and another surface (bed, wheelchair, etc.). As such, every physician should understand that the bone (or prominence) causing the ulcer should be used to identify the location of the ulcer. Following this nomenclature will eliminate much of the confusion regarding ulcer location.

Clifford A. Kaye, MD, ACP Member, Detroit

[Editor's note: The following is Dr. Pinson's response to the above letter.]

Dr. Kaye's comments about the clinical classification of pressure ulcer location are very much appreciated and informative. He is clearly correct that the ischial tuberosities are not situated at the lateral hip, which is formed by the greater trochanter of the femur. I certainly regret, and apologize for, this anatomical oversight.

Dr. Kaye's letter also highlights the difficulty and confusion associated with translating precise medical terminology into accurate code assignment that will properly reflect the patient's condition. This is particularly frustrating because the documentation requirements for code assignment may seem inconsistent with accepted clinical criteria; the location of pressure ulcers is an excellent example.

For correct coding of pressure ulcers, the physician should specifically identify for coders the location(s) assigned by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) as follows: elbow, upper back, shoulder blade, lower back, sacrum, coccyx, hip, buttock, ankle, heel or head.

Even if the coder knows that the greater trochanter is at the lateral hip, coding rules do not permit the coder to assign “hip” as the location unless clarified or specified as “hip” by the physician. So, using the bone or prominence associated with the ulcer to identify the location of the pressure ulcer—while clinically appropriate—may not suffice for coding purposes. If the pressure ulcer is not coded properly, its significance as a comorbid condition may be lost for severity of illness classification, quality scores, patient safety measures and reimbursement.

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Ask Dr. Pinson

Got a documentation or coding conundrum? Each month, Dr. Pinson will respond to selected questions from readers. Please e-mail your questions.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated