September 13, 2010

Coding’s Endgame
By Selena Chavis
For The Record
Vol. 22 No. 17 P. 18

More than ever, coders need to work with accurate discharge summaries to better serve hospital finances and patients’ well-being.

Consider the following scenario: A patient presents with pneumonia on admission. Over the course of the hospital stay, the patient is treated for the diagnosis, which later resolves itself. Following discharge, the attending physician dictates the discharge summary, noting the patient’s condition as bronchitis without mentioning pneumonia.

It’s a common occurrence, according to Joann Agin, RHIT, regional manager of data quality with Missouri-based Carondelet Health, who points out that discharge summaries should accurately reflect all confirmed diagnoses and all care administered during a patient’s hospital stay without introducing any new information.

In the case mentioned above, the physician neglected to reference pneumonia in the discharge summary, causing the coder to inaccurately code for bronchitis even though documentation throughout the chart reflected treatment for pneumonia. An outside reviewer eventually uncovered the error, and while in this case the bottom line worked in the hospital’s favor, industry professionals warn that more often than not, such mistakes can have a negative impact on compliance and revenue capture.

“[An accurate discharge summary] has always been the key to reimbursement … and it’s been the key to a good record,” explains Karol Richkus, RHIT, director of HIM consulting with Precyse Solutions, LLC, who adds that recovery audit contractor audits have brought the importance of the discharge summary to the forefront. “The discharge summary is a tool. … It shouldn’t be a new piece of information, [but] that is what happens often.”

Kelley Sears, RN, clinical documentation specialist at Caritas Christi Good Samaritan Medical Center in Massachusetts, says an accurate discharge summary should be a top priority because the documentation provides the basis for continuing patient care. “A complete and accurate discharge summary is important because that is what travels with the patient when they leave the hospital,” she notes. “The documentation is supposed to give you a chapter-by-chapter [synopsis] of what happened to the patient and should reflect the big picture of the hospital stay rather than just the final diagnosis. It’s the tool of communication between providers. … You can miss an opportunity to share some potentially good information for the care of the patient.”

Discharge Summary 101
Numerous governing bodies offer guidelines and requirements for completing a discharge summary, but professionals point out there is little standardization to the process.

“Every physician does a discharge summary differently,” Richkus says. “The main purpose is to understand what happened [during a patient’s stay].”

The Joint Commission mandates the following six components be included in a discharge summary:

• reason for hospitalization;

• significant findings;

• procedures and treatment provided;

• patient’s discharge condition;

• patient and family instructions (as appropriate); and

• the attending physician’s signature.

The Society of Hospital Medicine offers the following more-detailed guidelines as to what a solid discharge summary should contain:

• a statement about the reason for the hospitalization (the principal diagnosis);

• a list of medications with name (brand, generic, or both, as appropriate), dose, route, frequency, and when relevant, reason for as needed, written in lay terminology (Ideally, the list would indicate which medications were old, new, or changed and which medications the patient was on prior to admission that he or she should no longer take.);

• statements about what types of complications (related to the principal diagnosis or medication side effects) may occur and what to do if they happen (ie, warning signs and symptoms);

• a list of follow-up appointments for tests and clinical visits with their dates, times, and locations; and

• a list of relevant contact information (eg, principal care providers, Visiting Nurses Association, pharmacy, hospitalist).

Agin notes that while these standards and guidelines offer a basis for effectively documenting and communicating the discharge summary, more often than not physicians miss the mark. “It’s a timely issue,” she says, adding that documentation improvement initiatives should be designed to teach physicians how to sufficiently document the discharge summary to justify any and all diagnoses. “I know my coders have been complaining about how physicians are documenting this important piece. Oftentimes, the discharge summary can make or break your coding audit.”

The devil’s often in the details, Richkus points out, adding that while discharge summaries should not be too long, there should be enough detail to fully justify diagnoses. “Physicians often indicate uncertainty in diagnosis,” she says.

Sears adds that inaccurate discharge summaries often lack a representation of “a patient’s acuity, severity, and mortality while in the hospital.”

“Adequacy of Hospital Discharge Summaries in Documenting Tests With Pending Results and Outpatient Follow-Up Providers,” a 2009 study published in the Journal of General Internal Medicine, revealed that key information needed for continuing patient care is frequently omitted. While analyzing data for 668 patients, it was discovered that discharge summaries mentioned only 16% of tests with pending results (482 of 2,927). Even though all the study’s patients had tests with pending results, only 25% of discharge summaries mentioned any pending tests, with 13% documenting all pending tests.

“To me, [lack of detail] can have a detrimental effect on the patient,” Agin says. “In a perfect discharge summary, you have anything treated or completed listed.”

Common Issues
Lack of detail, a diagnosis with no support, lack of certainty in communicating a diagnosis—all of these areas represent the current state of affairs with discharge summaries in many hospitals, according to industry professionals.

“Doctors will often give all the symptoms but not clearly communicate a diagnosis,” Agin says, adding that while coders have previously been allowed to code “probables” and “possibles,” today’s healthcare climate demands a clearly stated diagnosis. “There’s more emphasis to have discharge summaries list all confirmed diagnoses,” she says.

Agin says some doctors do not even list the final diagnosis in a definitive manner. “It becomes more of a narrative sometimes,” she says. “I think it’s a matter of education.”

Sears notes that it often comes down to a lack of detail about the severity of the case. “They don’t specify a part of the diagnosis. You don’t want to overcode or undercode,” she says.

Identifying congestive heart failure as a common culprit, Sears says there are numerous coding options available based on severity. Coders require a confirmed diagnosis and clear communication of severity in the discharge summary to accurately code the condition.

“They [physicians] often don’t give you any specifics of severity,” Sears notes. “It not only can impact reimbursement, but it impacts the resources needed by the hospital to take care of the patient.”

According to Richkus, the most frequent diagnosis-related group errors that occur in relation to discharge summary documentation are associated with renal failure, stroke, sepsis, and pneumonia. Offering a typical example, she points to a patient who presents on admission with aspiration pneumonia. If the physician dictates the diagnosis as simply pneumonia in the discharge summary, an incorrect code may be applied to the chart.
“That’s two different reimbursements,” she explains.

Other documentation mishaps that create potential coding problems include physicians using arrows (up and down) to reference “hypo” or “hyper” and opting for trendy communication (such as what might be found in text messages) that isn’t necessarily mainstream.

“Some new physicians are making up their own abbreviations or using texting acronyms that no one understands,” Richkus notes. “A lot of our auditors have been seeing that.”

Timeliness in documentation has long been a concern for accurately recording discharge summaries, which physicians are required to complete within 30 days of discharge. “It’s not unusual to see discharge summaries completed two weeks later,” Agin says.

Because there is such a rush to get records out the door for reimbursement purposes, Richkus says some charts are being coded without the discharge summary. “A timely discharge summary is very important,” she says, pointing out that if the final documentation occurs after a record is coded, it can present potential compliance issues if the information doesn’t line up. “Auditors are going to the discharge summary and finding coding errors.”

The expanded use of hospitalist groups to treat patients during hospital stays has heightened the need for more timely and accurate discharge summaries, according to Sears. The concept of the hospitalist—or hospital-based physician—appeared about a decade ago, but it is rapidly becoming more widely used, according to industry professionals.

With the advent of declining salaries and managed care, physicians began to cut back on their hours and on-call responsibilities. Many healthcare organizations now use hospitalists to care for patients during emergency department visits and hospital stays. Key information is then communicated to the primary care physician after a patient is discharged, making timeliness and accuracy of discharge summaries important to follow-up care.

“The No. 1 issue would be how it affects a patient’s follow-up care,” Agin says. “It’s very rare that your [primary care physician] follows you in the hospital.”

“If your primary care doctor does not come to a particular hospital … without a proper discharge summary for follow-up, they are going to be treating you blindly,” Sears says.
When Richkus has worked with hospitalist groups, obtaining timely discharge summaries has proven to be an uphill battle. In a recent case in which a large hospital system was trying to get its documentation up to speed, she found that 50% of the records needing attention came from hospitalists.

“The use of hospitalists is a huge issue in this area,” she says.

Along the same lines as using hospitalists, Agin says multiphysician groups following patients in the hospital can create challenges when one physician fills in for another. “Sometimes if a doctor who hasn’t been following the patient does the discharge summary—especially if the patient was seen on only one day—the summary will not likely give a clear picture,” she explains.

The Bottom Line
As the final loose end tying up a complete patient record, the discharge summary has the potential to affect many areas of the hospital, including continuity of care, compliance, revenue cycle management, and overall hospital report cards.

“Once it’s coded, this information translates into mortality and severity ratings,” Sears says.

The consequences for not completing the necessary components of a discharge summary can be far-reaching. Richkus points to physicians who have held up as much as $400,000 to $1 million in potential revenue by not completing discharge summaries in a timely manner.

In such a case, a hospital may not have much recourse. “If a physician’s your top admitter, what are you going to do?” Richkus says.

Because they lack important detail for determining severity and present-on-admission indicators, Sears says coders should avoid coding directly from discharge summaries. “Here [Caritas Christi Good Samaritan Medical Center] we code throughout the chart,” she says, adding that the additional backup documentation can present a clearer picture and better case for compliance.

Agin agrees, noting that “it’s really the coders who are catching documentation errors.”

Some industry professionals believe the information captured in the discharge summary will become more complete in an electronic environment.

“When it becomes electronic, you can read it,” Sears says, pointing out how EHRs can help eliminate illegible handwriting and inaccuracies that can occur when information is difficult to read. “It also becomes easier to share information and communicate with other providers.”

Agin says some automation could prove beneficial for ensuring pertinent information is always included in a discharge summary for follow-up. “If it automatically pulled medications or labs, that would be good for follow-up,” she says. “You would still have to have input from the physician, though. That’s the challenge.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.