Accurate coding is imperative in the home health and hospice business. Reimbursement, financial planning, research statistics, and outcomes are all based on accurate documentation and coding. Complete and specific documentation and coding leads to better patient care and directs the plan of care in an efficient manner.
It is impossible to know all the synergistic relationships between OASIS responses and coding. However, it is critical that you are confident that all information entered is as accurate as possible and supported by the record. As a coding professional, it is important to speak the language of coding when asked for clarification of diagnoses from other health care providers so they can understand the importance of specific information and accurate coding.
A New Specialty that Offers More
In the past few years a new specialty has developed that focuses on obtaining and providing this information, which is labeled as a clinical documentation improvement specialist (CDIS). If you have been reviewing documentation and coding for any length of time you may well be on your way to becoming a clinical documentation improvement specialist. It is an option to consider because a CDIS helps to improve reimbursement and outcomes. As of 2014 about 80 percent of hospitals have a CDIS on board in order to improve their own reimbursement and outcomes.
Responsibilities of a CDIS
The role of a CDIS can be complex. First, a CDIS is responsible for reviewing medical records for incomplete, inaccurate or conflicting information and that all relevant conditions that require care throughout the patient’s episode of care are accurately entered. This means that the CDIS must have a good clinical (anatomy/physiology, pharmacology, pathophysiology) background, excellent coding skills and be able to discern the focus of care and what is relevant to the episode. Most have a health care related degree or certification.
Next, when the CDIS reviews the medical records, he/she looks for specificity of an illness and accuracy of documentation. When conflicting information is discovered, the CDIS must ask the physician for clarification. For example, if a physician documents congestive heart failure (CHF) in a patient’s medical record, but does not specify the type and acuity, the CDIS should ask the physician for a more specific definition of the type of heart failure. More specific codes result in better reimbursement rates. And, they also benefit all subsequent providers.
Most facilities have the ability for the CDIS to create a query in the record for the physician to address. If it is not addressed in a timely fashion the CDIS should contact the physician in person to discuss it. Physicians may not answer queries because they believe their documentation is already clear (or they have an aversion to paperwork!). This can result in a problem that trickles down. For instance, a patient comes to the ED with chest pain, an abnormal ECG, and an elevated troponin level, and is immediately transferred to the cath lab. The physician documents “chest pain” over and over in record, but never documents even MI, much less the site of the MI, because he believes it is very evident that the patient had a MI. The nurses know the patient had a MI, but the physician does not document it; therefore, it appears it did not happen and is not coded correctly. The patient is discharged and home health is ordered. The record has no documentation of MI and the coder is unable to obtain any clarification, so the patient’s treatment will not accurately reflect the treatment or diagnosis for the episode. If specific information is not documented or obtained, the home health or hospice coder is forced to use unspecified or symptom codes that are usually not case mix, and do not best represent the patient’s condition. There are many new codes related to MI and heart failure with new guidance as of 10/01/2017.
Develop a Relationship with your CDIS
Most physicians understand the necessity of accurate coding, and, with proper training by their employers, will eventually provide coders with the information they need! Providing the most specific information you can to your coder, whether in house or out sourced, increases your reimbursement, improves outcomes with a focused plan of care (decrease unnecessary visits) for the patient and your agency, and cuts down on time to submit the RAP. The CDIS professional is a good resource for confirming or obtaining specific diagnoses. Find out who they are and develop a relationship with the CDIS at your referring facilities – it will be worth it!
5 Star Expertise
The team at 5 Star Consultants offers the coding expertise needed to ensure your HHA is receiving the best reimbursement rates possible. 5 Star Consultant’s RN OASIS reviewers and coders have an eye for detail and years of home health/hospice experience to focus on the pertinent parts of the record for coding the home health episode. To learn more, please contact us at [email protected] or 866-428-4040.