By Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM 

I am always surprised by the circular path we follow in health care. In the early days of the COVID-19 pandemic the obstacles to continue to provide service and care appeared at first unmanageable. However, our large and sometimes bureaucratic systems did a 180 degree turn and closed all of our ambulatory care settings and redesigned the work force to provide inpatient care and post-acute management. 

In a short six-month time line the knowledge and successful management of COVID-19 was developed. Now, before vaccine trial results have been announced, health care systems are planning the systematic vaccination of our entire country. 

All this while health systems are still making strides in many other areas of medical and surgical care. This in most instances decreases our length of acute care stays and decreases the cost without decreasing the value of care. All said, this is a phenomenal testimonial to the rapid response of a nimble team of health care professionals who work hard to deliver high value health care for our patients.

However, all of these accomplishments, including great patient care, will not be recognized, nor paid for, unless properly documented. And sadly, we are still grappling with relatively simple concepts such as accurate documentation in the electronic medical record. Health systems face thousands of medical necessity denials a year for the payment of the medical treatment they have already provided, too often due to lack of documentation.

The historic large number of medical necessity denials require a qualified set of clinical professionals, (typically in the UR/UM and Physician Advisor) to review and decide if these denials are appealable. For those cases that can be appealed, an additional and significant team of health care professionals (physicians and nurses) write appeal letters and (or) conduct peer to peer discussions with the health plans’ physician advisors to fight for the reimbursement owed for the care provided. We have created a small industry within our systems to review, fight for and receive proper payment for services rendered. What remedies can be offered to mitigate work and cost that could be avoided with accurate documentation resulting in clear medical necessity in the first claim submitted?

Most of us are knowledgeable about the published criteria that hospitals and health plans use to gauge medical necessity for acute care hospitalizations. However, we also know that criteria is a guideline and the defining reason for a patient needing a hospital bed is the patients’ personal medical/surgical story. The electronic medical record is the patient’s plan of care and if the rationale for an admission and a continued stay is not clearly written, the chances of a payer denial are much higher, and, the need to appeal this denial on the backend through Utilization Management and Revenue Cycle is much greater. This extra labor and systems required also drives up the cost of care when the cost to collect is considered.

One consideration when working toward better documentation is the team approach. The focus of accurate documentation for the purpose of payment often is primarily been placed on the physicians. However, the entire interprofessional team has an important role to play in documenting the plan of care and the patient’s condition. Consider how the physical therapist documents the patient’s functional status, respiratory therapy documentation of patient’s response to the respiratory treatment provided, and clinical pharmacist’s documentation of the patient’s level of improvement with newly prescribed medications or lack thereof. We all have a deeper appreciation of the patient’s social determinants of health, and the social worker should document the barriers to improvement the patient may face on discharge due to their social circumstance. The cognitive and behavioral status is documented by the psychiatric and (or) neurology teams. The case manager drives the patient centric care plan and their ongoing documentation can serve as the care coordination strategy. All of this adds up to a total picture of the patient’s intensity and severity of illness plus the side benefit of higher quality care for the patient.

In addition to getting the whole team involved in documentation, the documentation must be of a high quality. Copying and pasting the progress notes of others as well as their own into a current note are not adequate. A clear progression of care needs to be documented and that cannot happen with yesterday’s notes. Perform regular audits to identify and reduce copy and paste.

Also, use denials due to poor documentation to educate the whole team on failures and wins. Develop feedback loops to the front-end caregivers to inform and educate on proper documentation. By doing so they will also ensure the patient is receiving the full benefit of their insurance.

As the Office of the National Coordinator (ONC) has implemented the CURES ACT Final Rule, patients will be more and more informed about their care and billing. The rule states that patients need more power in their health care, and access to their medical record empowers them to do so. (CMS, 2020) The patient’s medical record must be available to them at no additional cost. This is effective 60 days after the final rule is published in the National Register, so hospitals would be well served to add this to reasons to get documentation right.

Given the importance of accurate documentation for all the reasons identified here, we must put the full force of our collective expertise to provide timely, accurate, and succinct documentation in the patient’s medical record. If we can manage COVID-19, surely we can manage documentation.