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“He’s the best surgeon I know.”

Really? How do you know? Because he talks a big talk? Because it “seems” he doesn’t have many complications?

Hog wash. Show me the numbers.

Where do the numbers come from?

You guessed it, documentation.

Surgeons, let’s talk about it.

Getting Paid

First, it seems surgeons are more likely to be RVU based compared to their medical counterparts. Even though your clinic and hospital follow-up charges may seem small compared to your surgeries, the volume adds up and you want to make sure your E/M charges are where they should be.

Recently our surgeon group was audited and told they were “over billing.” But I reviewed their charts and discussed it with them, and I told them they were actually “under documenting” - a subtle yet important difference. But I don’t mean VOLUME of documentation, I mean PRECISE words they needed to get credit for their work. I showed them they could actually document LESS yet get credit for their higher bills (that were down coded). I talked about this in 3 previous issues: Part 1, Part 2, Part 3 (Time-based billing). It’s also the major focus of my video course for attendings (CME approved).

Comparing Apples to Apples

Surgeons understand quality conceptually. They want to know they’re doing at least as good as (ideally better than) their colleagues.

But how do you know that? Metrics, of course.

But how do you compare 1 to 1? You may have different patient populations. You may take on higher risk patients. That’s not fair.

Good news! There’s an app for that!

It’s called risk-adjustment! (It’s… Not actually an app… I’m sorry.)

Let’s look at mortality. The calculation isn’t “how many patients died” divided by “how many patients you did surgery on.”

It’s “how many patients died” divided by “how many patients were EXPECTED to die.” The lingo you might hear is “observed to expected” or “O to E.”

You want to reduce the numerator (the top) by providing good quality care, but increase the denominator (the bottom). How do you do that? By increasing their expected risk through the documentation of their comorbidities!

Let’s look at some examples.

Comparing Patients

Is the risk of death from a lap chole in a healthy 35-year-old female the same as an 81-year-old female with pulmonary hypertension, HFrEF (LVEF 25%), Uncontrolled Type 2 DM, HTN and COPD with chronic respiratory failure on 2L NC?

Of course not!

I know what you’re thinking: any reasonable person is going to have those differences documented. But the differences aren’t typically that obvious.

It’s more likely to be two 81-year-old patients, but one has hyponatremia and a BMI <19 and the other doesn’t.

Or they both did.

But in one case it wasn’t documented.

Get it?

Comparing Surgeons

Said another way (taken from Dr. Erica Remer with permission):

Surgeon A has a mortality ratio of 22%

Surgeon B has a mortality ratio of 14%

Which would you choose? Surgeon B, right?

Well… I hope you didn’t make a choice yet because you should ask, “What is their EXPECTED mortality ratio?”

Surgeon A’s expected mortality ratio is 35% because he sees the sickest of the sick.

Surgeon B’s expected mortality ratio is 5% because he sees simple patients.

NOW who would you choose? Likely Surgeon A.

But you have to make sure those comorbidities actually GET into your metrics. For that, they have to be “codable.” I talked about this in a previous newsletter. You may roll your eyes when you get a query asking, “Is that low sodium an abnormal lab only or is it hyponatremia?”

But coders can’t assume, and lab abnormalities (such as pseudohyponatremia and elevated potassium due to hemolysis) certainly exist. Symptoms and lab abnormalities are (largely) worthless. Diagnoses are not.

Other examples include:

💩 BMI >40
😍 Class 3 Obesity with BMI > 40

💩 Low Potassium
😍 Hypokalemia

💩 On home O2
😍 Chronic respiratory failure with hypoxia on 2L NC

So thank your neighborhood CDI nurse for that query - they just helped your metrics.

Sweat the Little Things

Think those “little things” don’t matter?

Each risk calculator is different but let’s look at a DRG change. Look at the weights on the right. (Highest tier, with MCC, is at the top. Lowest tier, without CC/MCC, is at the bottom.)

If you’re not sure about DRG tiers, CC’s and MCC’s, check out my previous issue. A weight jump from 1.67 to 2.3 to 4.5 is massive. Contrast that with an admission for afib where the weights go from 0.55 to 0.74 to 1.2:

Check out those jumps in the expected length of stay on the right.

If the length of stay isn’t already a focus at your hospital, I bet it will be soon as finances get tighter. An expected length of stay going from 2.9 to 5.1 to 9.8 days is huge.

Adding these “little” diagnoses such as hyponatremia or underweight with a BMI < 19.9 would take those up a tier. MCC’s such as acute metabolic encephalopathy, chemotherapy-induced pancytopenia, etc. would take them to the top tier.

Case Mix Index

You may have heard of case mix index. Simply put, this is how sick your patient population is. It’s the total “relative weights” of your patients divided by the total number of patients you cared for. Those “weights” come from documented comorbidities as I discussed above. Again, you don’t want this to be low compared to your colleagues, especially when used in conjunction with your length of stay, complications, mortalities, etc.

Complications

In my last newsletter, I talked about Patient Safety Indicators. Many of these are related to surgery, so check out that article too.

Op Notes

Op notes are to surgeons as discharge summaries are to hospitalists. You get hassled about finishing them so much you to start to see them only as a box to check and forget their clinical utility. For both, completing them sooner rather than later is certainly clinically helpful for communication.

But Op notes determine so much. Your progress notes may have stated you were going in for a one procedure, but the details of that procedure (gathered from the op note) could change the actual procedure from a PCS (Procedural coding) standpoint. Things like approach, or what and how much of a body part you removed, could impact the entire DRG which, again, goes into your total relative weights. This could be something as small as a biopsy.

And although I’ve largely avoided the topic, all of this also impacts how much the hospital gets paid. Just like the concrete company who refused to leave my property until I gave them a check after pouring my driveway, hospitals do need to get paid.

(You’re being hassled because of Joint Commission and Timely filing deadlines, by the way. That means if the hospital doesn’t “close” the chart in a timely fashion, the insurance straight up won’t pay).

A Final Note to Surgical APP's

I once talked to an APP working with a CV surgeon about all of this. Her collaborating surgeon’s mortality ratio (RAMI) was above 1. AKA not good.

A year later, she popped into my office. “What’s our RAMI, Dr. Oubre?! I have been documenting EVERY hyponatremia. Every obesity. Everything. Please tell me it’s less than 1.”

Indeed, it was now less than 1! She was ecstatic!

I had originally told her that understanding all of this and how to optimize documentation could become her specialty - a marketable skill. To that surgeon now, she’s irreplaceable. If he fires her, his metrics are almost certainly going to tank.

And for her? If she interviews somewhere else, she has hard evidence of how she could start improving another surgeon’s metrics on day 1.

That’s awesome.
That’s marketable.
That’s job security.

—

Thanks to the Ascension Providence Surgery Residency program for having me as a guest speaker last Wednesday for their grand rounds (and inspiring this issue)!

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, and my wife Kara (for grammar - yes I need that) for editing this newsletter!

When you’re ready, there are two ways I can help you:

Check out The Practical Guide to Attending Documentation.

• CME approved for 3.5 hours! Use your CME funds!

• Bill confidently (and reduce downgrades) and know what’s ACTUALLY needed for billing.

• Spend less time writing notes

• Use notes to PREVENT getting sued

Check out The Resident Guide to Clinical Documentation. The course that helps you:

• Impress your attendings and improve your evaluations.

• Prepare for real-world productivity pressures

• Gain the confidence to write shorter yet more effective notes.

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