Enter the RN-Coding Documentation Specialist
Getting specific -- Let’s see the effect of inaccurate codes.
A patient whose principal diagnosis is acute renal failure will fall into DRG 684, Renal Failure. If this patient also has signs of decompensating heart failure and the healthcare provider documents “CHF,” the hospital staff may expend time and resources treating this problem without it being reflected in the DRG. CMS expects the provider to indicate whether heart failure is acute or chronic, and whether it’s systolic or diastolic in origin. You explain to the healthcare provider that he must document the diagnosis as “acute on chronic systolic heart failure” to meet the CMS documentation standards. The DRG becomes 682, Renal Failure with Major Comorbidity, which indicates a higher severity of illness and a higher relative weight due to the increased resources needed to treat the patient.
The correct diagnosis provides a greater reimbursement and longer expected length of stay. The hospital is rewarded for diagnosing and treating the complicating condition when it’s properly documented, and the hospital is penalized when it isn’t.
Another patient has surgery for an “irrigation,” which normally can’t be billed by the hospital. When you talk to the surgeon and learn that she actually performed an excisional debridement, then show her how to document that in the medical record, you’ve turned a medical admission into a surgical admission with a billable OR procedure.
Based on your in-depth knowledge of both clinical and coding standards, you’ll educate the healthcare provider about the standards and formulate queries or clarifications, written requests to correct or improve the documentation, when the notes in active medical records are unclear or incomplete.
Although hospital coders are permitted to pose queries retroactively when they’re working with the discharged medical record, the record is more likely to come under scrutiny when entries to the medical record, particularly those that may increase reimbursement, are made after the patient is discharged. In addition, the coder must hold the medical record for final billing until the query is answered, delaying payment to the hospital.
Clinical experience a plus!
Although some CDI programs employ coders as CDI specialists, you, as a nurse clinician, can offer a unique perspective with clinical experience to support your analysis of the medical record. Speaking the language of healthcare providers, you can communicate with them as fellow members of the clinical team. Looking at progress notes, consultant reports, medication records, lab values, and radiology reports, you draw on your nursing background to predict or anticipate the diagnoses of patients being treated, and use your knowledge of coding rules to help the healthcare providers choose the right words to describe the diagnoses in CMS-friendly terms. You also work closely with other disciplines such as nursing and dietary, whose documentation helps support healthcare providers’ diagnoses and queries.
Hospitals count on their RN-CDSs to protect them from Recovery Audit Contractors (RAC), which are Medicare-contracted companies looking to recoup money that’s already been paid to the hospital, and to help them maintain positive scores with grading agencies and government entities that evaluate hospitals for the public. Complete and accurate documentation lessens the likelihood of a RAC’s success.
As programs develop and healthcare reform takes shape, the scope of practice of the RN-CDS will continue to expand. Some hospitals have asked their RN-CDSs to formulate queries for core measures, hospital-acquired conditions, patient safety indicators, quality indicators, and any other areas that can be enhanced through good documentation. Compliant documentation that neither overstates nor understates the severity of illness and resource utilization is a critical tool in shielding hospitals and healthcare providers from allegations of Medicare fraud and waste.
A completely new coding system, ICD-10, becomes mandatory in October 2015 bringing a dramatic increase in the specificity of documentation CMS expects from healthcare providers. RN-CDSs will be invaluable in helping healthcare providers navigate the new requirements.