Physiatry Practice Management Resources

Coding professionals have been strong supporters of having complete and accurate documentation in the medical record in order to accurately code and receive proper payment. With all eyes upon them, government agencies focus on fraudulent coding and billing practices, hospital administrators focus on declining case mix, increase in A/R days, the coders are torn, to code or not code without the discharge summary.

A variety of regulations exist for medical record documentation requirements, the more widely recognized are the Joint Commission on Accreditation of Healthcare Organizations and the Medicare Conditions of Participation. Both of these entities require that the discharge summary be completed within 30 days following the discharge. In contrast, the Office of Inspector General's (OIG) Compliance Program Guidance for Hospitals states "the documentation necessary for accurate code assignment should be available to coding staff." In addition, Faye Brown's ICD-9-CM Coding Handbook states in the section "The Medical Record as a Source Document" that "review of the medical record should begin with the discharge summary because it provides a synopsis of the patient's stay …" The regulatory agencies tell us when and what needs to be documented, but not in relation to having this documentation available for coding. Most coders must code inpatient medical records within three to five days of discharge in order to keep the A/R down to an acceptable level as defined by the hospital administrators. When the coders are coding within this requirement, the discharge summary is more often than not unavailable for coding the medical record.

Because there is so much attention and focus on preventing fraud and abuse, what should healthcare organizations do to ensure they are in compliance, yet at the same time maintaining the financial viability of the institution by keeping the A/R days down?

• Include a policy that allows coding without the discharge summary, if this is currently the practice.
• Develop a procedure for follow-up/recode to validate the accuracy of the coded/billed data
• Have a policy and procedure in place for coders to query physicians for clarification/specification of any documentation necessary to accurately code the medical record.
• Demonstrate to the medical staff the importance of complete and timely documentation.
• One important factor to consider when performing these "back-end" policies and procedures is the rebilling. Each organization should conduct a short, but thorough study to determine the impact on the organization of re-billing after the discharge summary is completed and reviewed for accuracy of the coded/billed data. Be sure to include the Corporate Compliance Officer or General Counsel prior to instituting such policies and procedures.

Physician documentation being timely, complete, and specific are the most important and key factors for accurate coding. With all factors being considered as discussed above, another alternative approach is the implementation of a documentation improvement process concurrently. Major benefits of such a process are the improvement of more timely documentation, more importantly having more specific or complete documentation. There is also an opportunity to improve communication with the medical staff to obtain any additional documentation needed for more accurate reflection of the patient care being received. Thus, coding without the discharge summary would be less likely a risk when all the documentation necessary to code the medical record is present within the content of the patient's record.

In summary, coders rely on documentation in the medical record to be complete and timely in order to accurately code the data. Each organization should establish both front-end and back-end policies and procedures to ensure compliance and that the facility is receiving the highest reimbursement allowable.

By: Joyce Belden