Updated on: June 22, 2012

What’s the Single Most Important Word in Medical Documentation?

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Original story posted on: June 1, 2010

clipsitz100If only physicians would make a habit of utilizing the word "because" in their documentation. I review medical records from our hospital clients across the country and get to see firsthand how poor physician documentation can lead to denials. Some doctors write fantastic progress notes, but others?  I can't even tell if the patient is sick.


Certainly, very few physicians clearly document the reasoning behind their treatment decisions. Records too often are silent as to why the patient needed to be admitted and why continuing care at the acute level was indicated. 


Following are three examples of cases in which sub-optimal documentation led to a denial:


1.   A hospitalist sees a patient suffering from chest pain in the emergency department at 11 p.m. and decides to admit him for chest pain evaluation. The documentation on the admission history and physical reads "Imp: 1. chest pain, r/o coronary artery syndrome - will get some trops, cards; consult in am"


2.   A busy pediatrician admits a child directly from the office for persistent vomiting. Admission note faxed from the office states  " Imp: dehydration - fluids"


3.   An orthopedist comes up to the floor after a long day in the OR to see his post-op total knees patient. He writes in his progress note "Doing ok. OOB. Taking po. P - D/C in am."


In each of these cases, the payer denied coverage based on alleged lack of medical necessity.    However, in the first two cases, admission was medically necessary and in the last case, the patient did require that additional day of care; the problem was that the physician's notes don't document the medical need for services. A painstaking review of the medical records reveals the following supplemental information:


1.   In the first case, the patient had blood work and EKGs in the ED that created suspicion for a heart attack. He had a history of heart bypass surgery and had been seeing his physician for shortness of breath during the previous two weeks.   The patient's chest pain came back after initial treatment in the ED. He required acute care for intravenous medications to treat his chest pain and heart rhythm.


2.   The child in the second case, who had not taken his medications, also had a rash, a temperature of 105 degrees off and on for two days and a severe seizure disorder. He needed acute care for intravenous fluids and anti-seizure and anti-nausea medications. He also needed close clinical monitoring for possible status epilepticus or prolonged seizures.



3.   In the last case, the elderly woman with the two new knees had a low-grade fever and just had started taking clear liquids that day. The cardiology consult was giving her magnesium intravenously. The orthopedist's note might have suggested to the payer that the patient was stable for discharge, but in fact she needed blood cultures and urine tests to check for infection, assurance that she was receiving adequate oral intake, and acute care for the magnesium infusion.


In all three cases, the supplementary information was buried in the medical record, and unfortunately did not appear in the doctors' notes. In my appeals, I bring the full story of the admission to the payers' attention to justify overturning the denial determination. But many times maybe there wouldn't have been a denial in the first place if the word "because" had been used.


In the first case the physician could have documented that the patient was being admitted because he had known coronary artery disease, blood work and EKG suggestive of a heart attack, new-onset shortness of breath that could be an early indicator for heart failure, and recurrent chest pain despite initial response to treatment - and because he needed acute inpatient services such as intravenous drugs to control pain and heart rate. Similarly, the other two physicians could have justified medical necessity for their actions by writing "Admit ...because..." or "Plan to keep hospitalized because...."

 

Of course, "because" is not a sure-fire remedy for inadequate documentation. But as a tool to organize a clinician's thoughts and to document the severity of illness and intensity of services required clearly, it's pretty helpful and not hard to remember.

 

The 2008 RAC Demonstration Project evaluation found that allegedly medically unnecessary services were responsible for 40 percent of overpayments - $391.3 million. On top of this, 8 percent, or $74.3 million, was directly due to insufficient documentation. This means that nearly half of all overpayments were related directly or indirectly to poor documentation.


At the present time, I think that most clinicians aren't aware of the role that their documentation plays in avoiding or appealing denials. Encouraging them to use the most important word in medical documentation - "because" - is a good place to start making them aware of what's at stake.


About the Author


Cynthia M. Lipsitz, MD, MPH, is a Senior Medical Reviewer with Washington and West, LLC, an appeals and denials management company.  In this capacity she maintains familiarity with current standards of medical care, Medicare and private payer hospitalization criteria, and coverage policies.   Dr. Lipsitz has reviewed records and observed documentation patterns from a variety of hospitals across the country, and has a heightened understanding of issues that lead to denials.  With over 25 years of experience in ambulatory and hospital medicine, public health administration, and health promotion software development, she brings an understanding of the realities of medical practice and administration to the field of denials management.


Contact the Author


c.lipsitz@washingtonwest.com


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