Electronic Medical Records

Stepping Up Your Documentation Game

Once upon a time, long, long ago, physician progress notes were a way of recording the patient’s condition and your treatments in the patient’s chart in order to communicate and ensure optimal care to the patient. You can lament that those days are gone but that will do you about as much good as lamenting that Homo sapiens are no longer Austrolopithecus. The progress note has evolved into a component of the hospital bill. Often times, what we write in the chart is not what we need to take care of the patient but rather what the billing department needs in order for the hospital to get paid.

In a previous post, I described the documentation game, where we use key words in the chart as adjectives to describe the patient’s severity of illness in order to lower the hospital’s mortality index. In this post, I’m going to show you how to use key words in the progress note to increase hospital reimbursement for inpatient care.

When a patient is admitted with an illness, the hospital gets paid by the insurance company (or Medicare/Medicaid) based on the patient’s primary diagnosis and not on how long the patient was in the hospital or how many charges the hospital accrued during the hospital stay. The hospital then gets paid more depending on the number of various comorbid conditions that the patient had at the time of admission – in other words, the sicker the patient, the more the hospital gets paid for any given primary diagnosis. So, in order to get paid as much as possible, the hospital has to be sure that all of those comorbidities are captured in the medical record. The hospital that documents comorbidities the best, wins the game. But there are a few rules to the documentation game:

  1. The comorbid conditions have to be documented by a physician. Conditions noted by a nurse, dietician, respiratory therapist, or social worker don’t count.
  2. The comorbid conditions have to be documented as being “present on admission”. If these conditions are in the emergency room physician’s note or in the admission history and physical, then they are considered as present on admission. However, if a comorbid diagnosis is identified and/or documented later in the patient’s hospital stay, then the physician has to state in a progress note that the condition “was present on admission”, otherwise, it doesn’t count.
  3. Diagnoses that only appear in a test result (lab result, pathology report, x-ray report, etc.) do not count. The diagnoses have to appear in an H&P, progress note, op note, procedure note, or discharge summary.
  4. Signs and symptoms don’t count.
  5. Lab values don’t count – only the physician’s interpretation of lab values count. So, you can’t just document that “the patient had a potassium of 2.5 so I will order potassium replacement”, instead you have to document that “the patient had hypokalemia so I will order potassium replacement”.
  6. The more specific you make the diagnosis, the more points you get and therefore the more you get paid.
  7. Using the words “likely, “suspected”, or “probable” in front of a diagnosis counts in the documentation game. You don’t have to know for sure that the patient has that specific condition.
  8. Certain words diagnoses that mean everything to you from a clinical management standpoint may mean nothing from a coding standpoint. So (as crazy as it sounds), urosepsis doesn’t count but sepsis does count.

In order to be sure that all of those comorbid conditions that were present on admission are captured in physician documentation, hospitals employ clinical documentation improvement specialists who comb through the charts to hunt for evidence that a patient had a particular comorbid condition that wasn’t documented by a physician. When they find one, they send a query to the attending physician or resident asking if the physician agrees that the condition was present and if so, asking the physician to add documentation to that effect in a progress note. Each of these diagnoses translates to a “risk adjustment factor” (RAF) number and when you add up all of the RAFs, the total score determines how much additional the hospital gets paid for any given admitting diagnosis.

Here are some concrete examples of how you can improve your hospital’s score in the documentation game:

  • A patient is admitted with a right lower lobe infiltrate and has type II diabetes with an elevated glucose. The patient also has chronic pain and has failure to thrive. Those two sentences get you 0 points. Now lets see what happens if you use some diagnosis words rather than signs and symptom words in your note: A patient is admitted with a suspected aspiration pneumonia (0.292 points) and has poorly controlled type II diabetes (0.496 points). The patient also has opioid dependence secondary to chronic pain (0.055 points) and has moderate protein calorie malnutrition (0.409 points). Now, those two sentences get you an RAF of 1.242 points.
  • A patient is admitted with suspected gram negative pneumonia and hypoxemic respiratory distress  with an increased lactate will get you 0.7028 RAF points and the hospital will be paid for a 2.8 day length of stay. However, if the patient is admitted with suspected gram negative pneumonia and chronic respiratory failure with an increased lactate, you now get 0.9469 RAF points and the hospital gets paid for a 3.6 day length of stay. Even better, if the patient is admitted with suspected gram negative pneumonia and acute respiratory failure with hypoxemia and lactic acidosis, you now get 1.3860 RAF points and the hospital gets paid for a 4.6 day length of stay.
  • A patient similar to the last one but has sepsis from a urinary source:
    • Urosepsis with SIRS, acute hypoxic respiratory distress, and an increased lactate” gets you 0 RAF points and no length of stay days.
    • Sepsis, acute hypoxic respiratory distress, and an increased lactate” gets you 1.0283 RAF points and 3.8 days length of stay payment.
    • Sepsis, acute respiratory failure with hypoxemia, and lactic acidosis” gets you 1.7660 RAF points and 4.8 days length of stay payment.

However, Medicare and insurance companies have determined that the documentation game wasn’t challenging enough so they added some more rules to make it harder to get RAF points:

  • For patients admitted with pneumonia, you get more RAF points if you can specify the type rather than just documenting “pneumonia”. So for example, “aspiration pneumonia” or “gram negative pneumonia” gets you more points. Don’t forget, that you are allowed to use the word suspected. So, for example, if you are prescribing vancomycin for a patient with pneumonia on the chance that they might have MRSA, put in your note “suspected MRSA pneumonia” rather than just writing “pneumonia”.
  • “Altered mental status” doesn’t count for any RAF points (it is a finding and not a diagnosis). So, instead, that patient has “acute encephalopathy” in your progress note.
  • “Unresponsive” doesn’t count but “unconscious” does.
  • “Drug-induced delirium” is a psychiatric code and doesn’t get you very many RAF points. It is better to document “toxic encephalopathy”.
  • If someone has a body mass index > 40, you get more points for documenting “morbid obesity secondary to excess calories” than you get for documenting “morbid obesity” alone.
  • For patients with heart failure, you get more points if you add the words “acute” or “chronic” and you also get more points if you add the words “systolic” or “diastolic”.
  • Avoid the word “dysfunction” as it doesn’t count for any points. So, for example, a patient does not have left ventricular dysfunction, they instead have left ventricular failure.
  • “Do not resuscitate” gets you no points but “palliative care” gets you lots of points. So, if you have a discussion with a patient and the patient decided to not undergo resuscitation, don’t document: “I spoke with the patient and he wants to be DNR“. Instead document: “I had a palliative care discussion with the patient and he wants to be DNR“. The terms comfort care, end-of-life care, and hospice care are all considered synonymous with palliative care when it comes to RAF points.
  • To maximize your RAF points, nobody should have “dementia requiring a sitter”. They should always have “dementia with behavioral disturbance”, “dementia with aggressive behavior”, “dementia with violent behavior”, or “dementia with combative behavior”.

The documentation game is by necessity a team sport and the team that wins will have both the strongest physician and the strongest documentation specialist. But it is not enough to be individually good, the physician and the documentation specialist has to work well as a partnership. Better cooperation between the doctor and the documentation specialist = more RAF points = more money for the hospital = better donuts in the physician lounge.

April 13, 2017


By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital