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“My hospital is telling me I need to document every comorbidity. Do I really need to do that?”

I get some form of this question frequently. So, it’s time to dedicate a newsletter to it. No, it’s not all about reimbursement.

I frame these discussions around the four purposes of documentation:

1. Synthesizing (To help you think and stay organized)

2. Communicating

3. Legal Protection

4. Billing

Let’s dive in.

Why Clinically?

You should be systematic with every aspect of clinical care, and documentation should be a part of that.

Say you pre-round on a patient and notice they’re mildly hyperkalemic. You schedule a few doses of Lokelma and move on.

The next day, it’s no better. You give a few more doses.

The next day, it’s even higher. You up your aggressiveness of treatment and make sure the patient is on a low K diet. That afternoon, a nurse mentions something about potassium supplements. You take a look at the patient’s MAR and realize they’re not only on potassium supplements but also on spironolactone and Lisinopril (both medications that can impact the potassium level). “Oh. Oops,” you say to yourself as you hold those medications.

I like to avoid “oops” in medicine. I’m sure you do too. How could documentation have prevented this?

If you not only had listed their Chronic HFrEF (a comorbidity) as well as their medications, these would have jumped out to you during the process of documenting:

Lisinopril, Aldactone and potassium supplements are staring you in the face, even if you’re just skimming over your own notes while writing. That mistake would have been caught days earlier. In my example, everything turned out okay. But if not, that would look quite bad in a court of law (which is my 3rd purpose of documentation: legal protection. Use documentation to prevent medical errors and the lawyers never come around in the first place)

Why for Communication?

A patient has partial aphasia and right hemiparesis from a previous stroke. However, no one documents that fact in any of the admission documentation. For various reasons, the patient is no longer on antiplatelets nor statin medications. A nurse notices the patient’s aphasia and right hemiparesis and sees no documentation of it. She therefore calls a code-stroke. That patient gets a stat CT head and CTA head/neck before someone notices older documentation suggesting that’s the patients baseline.

That was a medical error. Clear documentation of this aphasia and right hemiparesis from a prior stroke could have prevented that situation.

Why for Legal Protection?

Both of the examples above could result in lawyers getting involved. Use documentation to prevent those medical errors from occuring in the first place, and you don’t have to get to the other legal reasons documentation helps you.

I could tell examples all day long to drive home these 3 points. Unfortunately, most clinicians do not understand the far-reaching impacts documentation has on ourselves, our patients, and our colleagues, and do not take full advantage of this built-in tool to help us care for patients.

Quality Metrics

One way or another, and whether you’re aware of it or not, you’re being tracked by quality metrics. I’ve discussed these at length in previous newsletters (One for surgeons but applicable to non-surgeons too, and another about mortality ratios).

But, briefly, many metrics are “risk adjusted” these days. Meaning, they put everyone on an equal playing field because patient populations vary. So, these risk-adjusted metrics calculate the expected outcomes versus the observed outcomes (You may hear this as O:E ratio).

What impacts the expected outcomes? Those are based on how sick your patient population is.

What is that level of sickness based on? Often claims data.

What is claims data based on? Submitted codes.

What are the codes based on? Your documentation.

A neurosurgeon recently told me, “I wouldn’t go to me if I was a patient and saw these metrics. How do I fix these?” I left him with four major points:

1. Coders cannot code from previous documentation. It’s only from documentation during THAT encounter.

2. They cannot code from problem lists. It must be clear the diagnosis is impacting your care in some way (often summarized by M.E.A.T.: Monitored, Evaluated, Assessed, or Treated).

3. Coders are not allowed to assume. You must be explicit in your specificity of diagnoses and comprehensiveness. Examples:

   • Class 3 Obesity with BMI 44 > “Elevated BMI”

   • Hyponatremia > “Low sodium”

   • Chronic Systolic Heart Failure > “CHF”

   • Chronic respiratory failure with hypoxia > “On home O2”

4. Use your CDI and coding departments as a resource.

Lastly, Reimbursement

There are two main types of billing: Professional Billing and Hospital Billing.

Professional billing is how you get paid. That’s your RVUs based on CPT codes - 99214, 99223, etc. If you’re billing based on MDM, the list of comorbidities can help your complexity of problems.

And then there’s hospital billing, that’s how the hospital gets paid for… everything else. I’ve discussed DRGs in a previous newsletter, but, briefly, many inpatient stays are based on the DRG system whereby hospitals get paid a lump sum payment based on the main reason the patient is in the hospital. Very little can move that DRG one way or the other, but some comorbidities are considered Comorbid Conditions or Major Comorbid Conditions, and they can impact the DRGs and result in higher reimbursement.

On the outpatient side, if you belong to an ACO and/or take care of Medicare Advantage patients, then you’ve probably heard of HCCs. The comprehensiveness and specificity of diagnoses apply there as well.

These reasons, as well as quality metrics for the hospital, are the reasons you’re being told by your hospital to document as many comorbidities as possible. But, there’s a reason I listed those last. There are many other clinical, and self-preservation reasons, to optimize this practice.

That’s all for now. Don’t hesitate to ask questions as they help inspire future issues!

Cheers,

Robert

Thanks to Laura Samson, RN BSN CCDS, for editing this newsletter!

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