Complete Diagnosis Set and Patient as a WholeBy Erica Remer, MD, CCDS I don’t think about my previous life as a practicing physician much, but I took a little trip down memory lane this morning. When I was on my pediatrics rotation, I had a supervising resident who probably had the most profound influence on my career. Dr. Deirdre Bastible was soft-spoken, gentle and kind. But what impacted me the most was how she viewed the patient as a whole being. I never forgot how we were taking care of an intellectually impaired youth for an unremembered medical reason, but she noticed he had a very nasal voice. She confirmed with his parents that he was incessantly teased for the way he talked, and, furthermore, he did not sleep well. Several days later, he was discharged minus some adenoids and tonsils. I’m not sure you could fly that past an insurer nowadays, but the point was she didn’t just hyper-focus on his principal diagnosis. Deirdre assessed the patient as a person and addressed all of their needs. I tried to emulate her, and, in the emergency department, I would try to list all the conditions I felt were important to the patient’s (not) well-being. I didn’t know, and I didn’t care, that this practice would be valuable to the hospital’s reimbursement or quality metrics. This morning, I popped onto Twitter for something and discovered Ron Hirsch had tried inserting me into a conversation in May. Amy Townsend, a hospitalist from Texas, was complaining about evil CDISs trying to make her diagnose malnutrition when she is just trying to take excellent care of her patients. She is convinced that the hospital is just trying to jack up their reimbursement, and she wants them to extricate themselves from her and her patients’ relationship. Yeah, can’t answer this in a 140-word Tweet, hence this essay. It reminds me of a hospitalist I worked with when I was a physician advisor. He also refused to document malnutrition as a diagnosis. His reasoning was that he did not feel he was not competent to make that diagnosis; he felt it was a diagnosis for the dietitian to make. I tried to get him to see that he was considered captain of the ship, and it was his responsibility to corral all the pertinent diagnoses made by him, his colleagues, and the ancillary staff, on his patient. I am trying to get the emergency medicine providers I am auditing to consider their diagnosis set as a means to convey the entire encounter. Because historically providers only need a single diagnosis to justify the medical necessity of their Evaluation & Management level of service, they often only list one. Convenience? Expedience? I hope not laziness. This practice does not tell the story of the encounter. It may not support medical necessity for all tests and procedures. It does not help the hospital establish POA (present on admission) status for pertinent conditions. It doesn’t convey to the next provider the conditions which are relevant and important to the care of the patient. In my emergency medicine CDI project, I model the diagnoses I would have made and the sequencing. Complete, specific, with acuity and linkage. The ED doctor documented “abdominal pain and hyperglycemia,” and I counter with:
My list tells a story. “Syncope” is not a diagnosis which support inpatient status, whereas the follow list could:
Patients don’t get admitted for COPD. They get admitted for a COPD exacerbation, often compounded by acute or chronic hypoxic respiratory failure. The don’t get admitted for a fall. They get admitted because they have fractures which need definitive treatment. “Altered mental status” does not have the same implication as “profound metabolic encephalopathy.” Amy, malnutrition matters. Not to line the hospital’s pockets (which incidentally line your pockets, too, as a hospitalist). Malnutrition is important because it is considerably more difficult to cure or manage your patients’ underlying disease processes without addressing their nutritional status. The A.S.P.E.N. Consensus Statement says it “is a major contributor to increased morbidity and mortality, decreased function and quality of life, increased frequency and length of hospital stay, and higher health care costs.” As a clinician, you must recognize factors which put your patients at risk of having or developing malnutrition – stressors like trauma, acute and chronic illness, advanced age, inability to eat. Twenty to fifty percent of YOUR hospitalized patients are likely to have undernutrition (the rest are probably obese or morbidly obese, but that is a story for a different day!). You should be utilizing resources to combat malnutrition; there is no magic dietitian fairy. Dietary supplements and artificial nutrition, bed padding and nursing time turning patients to prevent bony protuberances developing decubiti cost money. Your hospital gets compensated for resources utilized according to the codes submitted to the payers. Dr. Townsend, if you aren’t using those resources because you resist diagnosing and documenting malnutrition to spite your “idiot CDI people” and your administration, shame on you for neglecting your Hippocratic oath. If you are the advocate for actual patient care that you profess to be, and you are treating malnutrition appropriately, then you should respect that hospitals need to recoup money for resources they have utilized. You will not work long for a hospital that perpetually runs on a deficit. Now, if your CDI folks are really trying to get you to document diagnoses which are not present in your patients, THAT is a different story. In an ethical practice, the CDISs should be finding clinical indicators that intimate an undocumented diagnosis and generating a query. CDI queries are a question, and your answer is allowed to be no. But don’t say no just to be vindictive. That would be doing a disservice to your patients. If you believe the CDISs are not practicing according to the ACDIS Code of Ethics (https://acdis.org/membership/ethics), report that to management. Be like Deirdre. Take care of your whole patient, document what you did, and let the reimbursement do what it should. Don’t worry about DRGs and CC/MCCs. Tell the story and tell the truth. |