By: Linda Fotheringill, Esq. and Cynthia M. Lipsitz, MD, MPH

There are many of us physicians and other healthcare professionals who regularly write notes in medical records, but are not yet fully aware of the relationship between our documentation practices, medical coding and reimbursement. The complexities of coding and DRGs are tiresome to busy physicians, so we thought a clinical story might be helpful.

Once upon a time, a surgeon was consulted to evaluate and treat a pressure ulcer. The patient was recovering nicely from the infection and dehydration that brought her in, but the ulcer needed to be treated before she was discharged.

What the Surgeon Did

The surgeon arrived at the patient's bedside promptly, photographed the wound and meticulously measured the ulcerated area. He probed it for depth and undermining. Using scissors and forceps, he cut away all devitalized tissue beyond the margins of the ulcer until he could see healthy pink tissue. There was a moderate amount of controllable bleeding. He dressed the wound and wrote detailed orders for continued management.

What the Surgeon Wrote

"Wound debrided with scissors. Irrigated and dressing applied. Patient tolerated well. Dressing orders written."

What Happened Next

The patient's attending physician promptly dictated a discharge summary.  In medical records, the procedure was coded 86.22, "excisional debridement." A DRG was assigned based on the principal diagnosis, comorbid and complicating conditions, and pertinent procedure. The hospital billed $30,000 appropriately and was reimbursed.

The procedure code 86.22, however, triggered a government audit. The auditor read the surgeon's note with the Coding Clinic in mind. The pertinent section states:

"The use of a sharp instrument does not always indicate that an excisional debridement was performed. Unless the documentation describes sharp debridement as a definite cutting away of tissue and not the minor removal of loose fragments with scissors or scraping away of tissue with a sharp instrument, assign code 86.28 (removal of devitalized tissue, necrosis and slough)."

As a result, the government auditors determined that the DRG for this hospitalization should be revised, which dropped the reimbursement amount to $19,000. Sadly, an overpayment of $11,000 was alleged to have occurred, and this amount was in jeopardy of being recouped by Medicare.

The surgeon, billing separately for his services, was reimbursed fully for an excisional debridement.  (However, it is expected by many experts that government auditors soon also will be looking to recoup physician payments for improperly coded and paid procedures.)

Sadly, the surgeon never learned of the hospital's situation, and the next week, the surgeon wrote the same note.

Meanwhile, the hospital appealed this case and finally was able to overturn the excisional debridement denial many months later, after an Administrative Law Judge hearing.

The Moral(s) of the Story

If it isn't written down, it didn't happen. The surgeon provided excellent care, but for whatever reason he didn't write a detailed note. All of us in healthcare are taught to do this, but knowledge doesn't always translate into practice.

What IS written down must be specific. A note doesn't necessarily have to be lengthy, but it must communicate enough to allow accurate coding. Describe in detail what was done.

If the note isn't specific, ask the writer. How to query is another topic unto itself. But in a nutshell, do it promptly, simply, and in person if possible so you can discuss things for clarification and not have to send notes back and forth.

If the writer isn't told how to fix things, he'll do it again. It's not just the coders' job to inform physicians, nurses, physical therapists and others who write notes about poor documentation. Regular feedback from hospital administration will raise awareness of the documentation-to-dollars relationship.