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Anesthesiologists can become critical facilitators of improved documentation of comorbidity,resulting in safer patient care and enhanced revenue for surgical patients.

Introduction

Hospitals aggressively encourage physicians to document their patients’ comorbid medical conditions to enhance patient safety and provide enough information for hospital coders to determine the most appropriate diagnostic-related groups (DRGs) for inpatient and outpatient services. Not only can inadequate communication of coexisting patient illness lead to medical errors, which ultimately increases insurance costs, but failure to provide the appropriate documentation can result in lower-weighted DRGs, leading to a dollar-per-case reduction in payment. Unfortunately, a significant difference exists between common clinical terminology and the arcane nomenclature used by coding and billing systems. As a result, physicians and hospitals are frequently not documenting patient severity of illness sufficiently to obtain full reimbursement for all services rendered. For payers, inadequate coding may result in unplanned complications, can effect actuarial data, and makes it difficult to plan adequately for costs of care. Alternatively, hospital reimbursement can be dramatically impacted in a positive fashion by minor DRG changes driven by proper documentation. A study reported in the January 1997 Journal of Clinical Monitoring found at least one additional diagnosis in 22 of 180 charts, resulting in a 1.5 percent increase in reimbursement for the hospital in a study of comorbid documentation.

In addition to improving reimbursement, accurate comorbid disease documentation is critical to the process of accurately categorizing the patient’s severity of illness (SOI) and risk of mortality (ROM), determined using the all patient refined DRG (APRDRG) classification. This instrument bases SOI and ROM classifications entirely on coded data reported for billing, utilizing the UB- 92 form and is used by regulatory bodies and industry groups such as the JCAHO and the National Committee for Quality Assurance for comparative profiling of hospitals. Without adequate physician documentation of comorbidities, hospitals that care for sicker patients may be unfairly compared to peer hospitals with lower severity levels, resulting in higher than deserved complication, mortality, and cost ratings. More than 30 states use the APR-DRG classification to provide report cards comparing hospitals on a regular basis.

This distinction will become even more significant as CMS (Centers for Medicare and Medicaid Services) and other payers migrate to the APR-DRG system for reimbursement. Hospitals in Maryland are piloting a process for reimbursement using this system and CMS has published its intention of differentiating hospital reimbursement based on SOI.

Figure 1. An anesthesia electronic medical record with automated charge capture provides a tool for easy documentation of coexisting conditions for medical records coders.

Improving Documentation In 60 to 70 Percent of Hospital Admissions

Anesthesiologists are uniquely poised to facilitate and augment the documentation of comorbid conditions leading to more precise severity of illness classifications. First, anesthesiologists evaluate and document the medical conditions of a very large subset of hospital admissions – those patients scheduled for surgery – often the entry point of 60 to 70 percent of inpatients.

Second, since the pathophysiologic events that occur with the trauma of surgery and the perioperative administration of anesthetic and pain-relieving drugs often affect the patient’s physiologic function to a great degree, anesthesiologists are careful to document presurgical dysfunction. Coexisting disease and surgical procedure, for example, have been shown to be the most important determinants of outcome. A complete patient history, including comorbid conditions, is a vital first step in determining the anesthetic plan; documentation of that history is the start of a defensible anesthetic record.

Third, anesthesia providers are increasingly required to demonstrate medical necessity to justify the presence of anesthesia service for several procedures. This medical necessity justification alludes to comorbid conditions that, if they exist, would indicate to CMS, in particular, that a patient was at a higher risk than another cohort without similar comorbid conditions. Consequently, a surgical procedure which may have been adequately performed under local anesthesia only (with no anesthesia service) requires the involvement of the anesthesia provider to ensure proper medical care of the patient during the surgical procedure. More and more often, therefore, the anesthesia billing office is required to provide correlating comorbid ICD-9 diagnosis codes on their claims submission forms.

Fourth, with the establishment of the National Correct Coding Initiative by CMS in 1996, it became imperative that the anesthesia provider generate identical code sets to the surgeon and the facility. Consistent variances from concurrence of these codes by either entity may prompt an audit under the auspices of the Office of Inspector General. Specifically for anesthesia, this task involves the selection and documentation of appropriate surgical cost per thousand (CPT) codes.

Improving Comorbid Documentation

An anesthesia electronic medical record (AEMR) system that includes automated charge capture provides a unique opportunity for physicians to generate specific procedure and diagnosis codes at the point of care, where corroboration between surgeon and anesthesiologist can provide pinpoint accuracy. This is particularly helpful in making sure the hospital, surgeon, and anesthesiologist bill for the same CPT code, using the same surgical diagnosis – avoiding one reason for claim rejection and saving costs for both hospitals and payers.

By using a digital preoperative assessment tool, the anesthesiologist can easily define and document the presence of various comorbid conditions, providing medical necessity documentation simply by completing the preoperative history and physical. However, by using an embedded encoder within the EMR system, they also are capable of providing up to fivedigit specificity of ICD-9 diagnosis coding on all medical conditions for all surgical patients. These comorbid conditions, documented in the terminology of billing, are essential in the determination of the appropriate DRG classification.

The resulting coding report provided by the AEMR allows the medical record coding personnel to more easily locate and incorporate the physician’s documentation of surgical procedure, diagnosis, and comorbid conditions into the UB-92 for billing. The same process, used in outpatient surgery, may document the medical necessity of ancillary services and testing, frequent sources of denied reimbursement.

The Value of Improving Comorbid Condition Documentation

CMS has developed a list of diagnoses recognized as conditions that make surgical patient management more difficult. Documenting the presence of such conditions is critical to the process of accurately categorizing the patient’s severity of illness, risk of mortality, and the correct ICD-9 classification. This list includes:

• Acidosis;
• Acute blood loss anemia;
• Angina;
• Atrial fibrillation;
• Chronic blood loss anemia;
• CHF or history of CHF;
• COPD or history of COPD;
• Diabetes mellitus (Type 1 or “uncontrolled”);
• Dehydration;
• Malnutrition;
• Pneumonia;
• Pathologic fracture;
• Phlebitis (IV site or leg); and
• Respiratory failure.

Figure 2 illustrates the financial importance of capturing comorbid condition documentation.

Figure 2. Examples of Differences Resulting From the Documentation of Surgical Comorbidities/Complications

Certified coders are limited to the quality of documentation in the hospital record (e.g., history and physical, progress notes, discharge instructions, discharge summary) and are not allowed to interpret laboratory findings or other indications of comorbid conditions. Using the encoder, however, the anesthesiologist can answer basic medical condition questions that lead to various ICD-9 diagnosis codes. These varied diagnosis codes may contribute to unique DRG classifications resulting in significantly disparate reimbursement payments.

In an era of increased scrutiny of fraud and abuse, one of the components of HIPAA requires that each institution must continuously guard against situations where upcoding occurs. Anesthesiologists are capable of generating this level of comorbid documentation without concern of upcoding. The professional fee for this group of physicians has no correlation to the DRG classification, so there is no incentive for these physicians to upcode. By using the encoder, these physicians are simply being directed to answer specific medical conditions without knowledge of the resulting effect on DRG classification. However, as demonstrated in Figure 2, it is clear that generating the specific comorbid severity of illness may have a profound effect on the resulting DRG classification.

As CMS and other payers migrate to APR-DRG classification for reimbursement, accurate capture of all comorbid conditions will be vital to the financial success of the institution. A primary difference between the CMS DRG system and the APR-DRG system is that all secondary diagnoses have the potential to affect SOI and ROM. Clearly an increased focus on comorbid conditions will have profound effects on reimbursement as well as comparisons of institutions by outcome. Furthermore, understanding that any changes in CMS reimbursement will need to have budget-neutral results, it is highly probable that as the reimbursement for higher risk patients increases, the reimbursement for lower risk patients will decrease. This will make it imperative that each facility aggressively determines all the appropriate comorbid conditions for their respective case mix.

This degree of specificity will only occur with motivated physician input. Since the professional fee component for an anesthesiologist does not correlate to the DRG classification system, a reasonable question would be how to devise a methodology to provide incentives for the anesthesiologist. By incorporating the encoder within the preoperative evaluation process, anesthesiologists would have the necessary tools at their disposal to generate this level of specificity. However, why would the anesthesiologist spend the time necessary to accurately document this level of comorbid documentation on all patients rather than only on those cases that require medical necessity for anesthesia services? Each facility must answer this question individually; however, it is evident that the financial stipends currently being allotted, or requested, by the anesthesia department may be justified if the group provides additional value for the institution by spending the time necessary to generate comorbid documentation on the large subset of patients scheduled for surgery.

Investment in an AEMR that incorporates means for granular comorbid condition documentation puts excellent tools in the hands of a uniquely qualified physician group to enhance patient safety, maximize hospital revenue, justify ancillary testing preoperatively, assure proper classification of patient risk factors for benchmark comparisons between facilities, and speed the return on IT investment.