Everything We Do Is Being Measured – Does it Matter?

“Why can’t doctors just be doctors and take care of patients?”

This is a question that I am sure many have heard repeatedly from physicians who are tired of the increasing administrative burden of documentation. In my opinion, some of it is well founded. In my 20-plus years of practice in the hospital, the office, and at nursing homes I never once heard or used the term “functional quadriplegia.” But now that term seems to have great significance.

For years, “urosepsis” was commonly used and well understood to represent the patient with a urinary tract infection that also had sepsis. In ICD-9, “urosepsis” coded to severe sepsis but in ICD-10, “urosepsis” codes to simple urinary tract infection. Physicians had to document “UTI with sepsis” to allow the selection of an ICD-10 code that properly portrays the patient’s acuity. Why someone, likely non-clinical, decided that a commonly used, commonly accepted, and compliantly codable term was no longer acceptable is hard to comprehend.

But, on the other hand, the patient’s life may depend on the doctors thoroughly and accurately documenting the care provided to the patient. Every member of the care team relies on each other’s documentation to provide care. The physician called to the bedside at 2:00 a.m. for a patient’s acute change in condition needs to be able to determine the patient’s condition prior to the event. The nutritionist needs proper documentation of the patient’s medical conditions to properly develop a dietary plan and education. The pastoral care team needs to understand the patient’s condition and prognosis to be able to provide spiritual counseling. As outpatient case management and disease prevention programs grow in the office setting, documentation is essential to allow all team members to provide the best comprehensive care to the patient, addressing both the medical and social drivers of health.

The many reasons for measuring care

Patient care aside, the other importance of thorough documentation is the myriad of organizations measuring our care and using it for a myriad of purposes. Everyone is aware of Medicare’s use of the primary and secondary diagnoses that are assigned as Comorbidity or Complication (CCs) or Major Comorbidity or Complication (MCCs) on inpatient admissions for assigning the appropriate Diagnosis Related Group (DRG) and paying the hospital for the admission. Depending on the case, a few clinically appropriate words in the medical record can result in an increase in tens of thousands of dollars for that admission, money that covers the added costs incurred by that patient compared with the patient without that condition.

Medicare Advantage organizations are paid a monthly payment for each enrolled beneficiary that is based on the patient’s diagnoses, reported as Hierarchal Condition Categories (HCCs) that determine the patient’s Risk Adjustment Factor (RAF) score which is multiplied by the baseline payment rate. For these organizations, they argue, this additional payment is justified and allows them to cover the added costs of caring for these patients and providing supplemental benefits like dental and eye care.

And since little in health care is simple, the assignment of diagnoses as CCs and MCCs has no correlation with the assignment of diagnoses as HCCs. Thousands of ICD-10 codes falling or not falling into hundreds of CCs, MCCs and HCCs means the only rational plan is to document thoroughly and accurately, whether the diagnosis directly affects payment or not.

While we usually think of HCCs influencing payment to Medicare Advantage plans and discount the effect of documentation in the office setting for physicians, more physicians than ever are participating in bundled payment programs, either voluntarily or involuntarily. CMS continues to tout their goal of having 100% of traditional Medicare beneficiaries and the vast majority of Medicaid beneficiaries in accountable care relationships by 2030.

And in any of these programs, accurate documentation, diagnosis specificity, and ICD-10-CM diagnosis coding for care in the office is crucial to ensuring the accurate representation of the patient population, both in calculating payment to the provider and in public-reported performance scores. As physician pay from CMS under the fee-for-service model continues year after year to decline, accurate, complete documentation to capture all of the patient’s conditions allows physicians to be paid at a more equitable rate for the care they provide, minimizing the negative influence of the Congressionally mandated yearly negative payment adjustments.

The quest for quality and accountability

But CCs, MCCs and HCCs are not the only places where there is money at stake. CMS has several quality payment programs, including the hospital readmission reduction program, value-based purchasing program, inpatient quality reporting and hospital acquired condition reporting programs where every diagnosis has the potential to be considered a qualifying or modifying condition, or a code that excludes the patient from the dataset. The patient safety indicator technical specifications alone have 20 megabytes of information to define the measurements, presenting an insurmountable challenge to try to figure out which codes are “important” to capture and which are not.

Then there are the external agencies that are measuring everything that is done by providers in the office, in the hospital, in surgery centers, in nursing homes and more. And that data is increasingly available to the public for them to make their choices about where to seek medical care. Medicare uses their claims data to produce Care Compare, a consumer-friendly site that uses an overall star rating along with availability of more granular data. Like most, this system uses objective data, such as data from the patient safety indicators, along with much less objective data from patient satisfaction surveys.

Aside from CMS, other organizations have gotten into the provider rating business, perhaps to improve health care in the US but also to make money. Both Leapfrog Group and US News and World Report accumulate internal and external data and publish ratings but unlike CMS, if a provider wants to promote their performance, they must pay thousands of dollars for the right. Organizations like Healthgrades also have a similar model with options for providers to advertise on the site to attract new patients.

When I am asked by doctors why they cannot “just be a doctor,” I explain the realities of our health care system that includes complete and accurate documentation. I also like to use the analogy that I would presume not one single law enforcement officer chose their occupation because they wanted to write tickets for jaywalking or sit at a desk and fill out reams of paperwork for every arrest they make, but those duties are part of the job. Our patient’s health and lives depend on all parts of the excellence of our medical professionals, from the clinical care they provide to the documentation of that care.

To learn more about capturing and coding the full patient encounter, visit PCSRCM.com/clinical-integrity.