June 22, 2015

The Corporate Cultural Trap

By Allen Frady, RN, BSN, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

With the impending implementation of ICD -10, physicians’ already stressful schedules are about to get even more packed. There is little doubt that the conventions of the ICD-10-CM and PCS systems represent a major paradigm shift in how we track our patients’ health issues and outcomes – or more specifically, how we capture patients’ illnesses and histories in codes. At the center of the discussion is physician documentation. 

Physicians often are surprised to learn that the only impact they truly have on issues of quality, outcomes, profiling, and reimbursement is associated with the information that coders derive directly from their documentation.

Hospitals across the country small and large spend an exorbitant amount of time trying to determine the best method for improving their quality scores, profiling, and case mix index without adding additional tasks to medical staffs that often are already overtaxed. This is not just a noble endeavor; it is a non-optional survival tactic. The carrot is that physicians will admit many sick patients to the hospital, filling beds and keeping the gears of healthcare turning. The stick is that if you bother the doctors too much, they simply will admit patients elsewhere, which can significantly impact the health of the hospital. The solution: don’t bother the doctors. 

As with many treatments, the fix here is just as bad (or worse) as the disease. By not enforcing proper documentation conventions, you are significantly damaging vital pieces of your facility’s lifeline, including your ranking against competing facilities in measures such as length of stay, costs of care per insured individual, quality-related outcome measures, and direct revenue. Remember that all of these scores are risk-adjusted based on how sick your patients are. If you are not accurately capturing the severity of the patients you are caring for, the expected costs and length of stays will be inappropriately low while the expected health outcomes for your patient population will be unrealistically high. 

The problem itself reveals that the solution will not be attained without physician participation. To put it simply, physician involvement with regard to issues of physician documentation is not optional. This may sound like a sarcastic quip and might even be funny if only it wasn’t exactly what administrators of many facilities fail to do.

“I can’t ask Dr. Smith that question” often can be overheard intermingled along with questions such as “Why is our case mix index so low in spite of the fact we are working so hard?” As the old adage goes, do not confuse effort with results. Presenting your program as a benefit is not a tactic that always will go over well in the new age of healthcare. Sooner or later you will be asked to present what you have accomplished. 

A good ICD-10 implementation plan usually begins with coder training. Clinical documentation improvement (CDI) and physicians must be included along with proper IT, billing, tracking, and electronic medical record (EMR) testing. These are the standard pieces of ICD-10 planning and have been for a couple years now. As we near the deadline, it is time to dig into the next level. Rather than just understanding the coding system, it’s time to begin looking at actual documentation in relation to how to mitigate potential negative impacts of implementation. If you haven’t already begun giving these issues a serious look, now is the time.

Hospital administrators and revenue cycle directors take note: if you have historically had less than ideal physician cooperation, you still have a narrow window of time to address this problem and develop a strategy for improvement. Physician behavior modification is the new non-optional corporate culture convention. The potential catastrophic consequences of having records full of symptomology rather than codeable diagnoses when ICD- 10 hits are not to be taken lightly.

About the Author

Allen Frady is a consultant with experience in management, implementation, education and clinical practice.  With 20 years in healthcare, he provides his clients assistance in the areas of documentation, program implementation and compliance.  His background includes critical care nursing, coding, auditing, utilization review, and documentation improvement.

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