Inpatient Practice

The Documentation Game

board-gameOur hospital finished the last year with an inpatient mortality index of 0.54, a fantastic accomplishment. That means that we provide great care and we play the documentation game well. If the hospital mortality index is 1.0, that means that you had exactly the number of inpatient deaths that other hospitals have on average, after those patients are adjusted for their case mix index (CMI; a way of quantifying how sick the patients are). If your mortality index is > 1.0, then you had more deaths than the average hospital and if it is < 1.0, then you had fewer deaths than average. Another way of stating this is that the mortality index is the ratio of observed: expected mortality. At 0.54, our mortality index is one of the lowest of all hospitals in the country.

There are two ways you can keep your mortality index down: you can have few deaths (observed mortality) or you can document that you take care of a lot of sick patients. The best performing hospitals do both. As an example, your mortality index will be high if you have a young patient who came in for an elective cholecystectomy die (low expected mortality). On the other hand, if you have a 90-year old who has leukemia, is in heart failure, and is on dialysis come in for an emergent appendectomy and he dies (high expected mortality), your mortality index does not go up so much.

So if you want to be a best-performing hospital with a low mortality index, it is not good enough to just take great care of your patients, you have to document how sick they are. That’s where documenting secondary diagnoses that are present on admission becomes critical… and that’s where most physicians fall short. The hospital coders have to be able to pick those diagnoses out of the admission history and physical examination so it is necessary that the history and physical exam contain the precise words that indicate those secondary diagnoses that can significantly impact the case mix index. Words matter: you can’t just write “potassium = 3.0, will give KCl”, you have to actually write “hypokalemia, will give KCl”.

Here are the top secondary diagnoses that affect the expected mortality score:

  1. Anemia (specific type of anemia and whether it is acute or chronic)
  2. Acute respiratory failure
  3. Coagulopathy (including use of anticoagulants)
  4. Heart failure (systolic or diastolic; acute or chronic)
  5. Chronic kidney disease (including the stage number)
  6. End-stage renal disease
  7. Diabetes (including whether it is type I or type II, controlled or uncontrolled, and what organs have manifested complications)
  8. Hyperkalemia
  9. Hypokalemia
  10. Hypochloremia
  11. Hypomagnesemia
  12. Hypophosphatemia
  13. Hyperphosphatemia
  14. Hypocalcemia
  15. Hypercalcemia
  16. Hyponatremia
  17. Hypernatremia
  18. Dehydration
  19. Hepatitis (A, B, or C; acute or chronic)
  20. Liver disease
  21. Protein calorie malnutrition (mild, moderate, or severe)
  22. Metastatic cancer (including what organ it metastasized to)
  23. Decubitus ulcer (including the stage number)
  24. Pleural effusion
  25. Pulmonary edema
  26. Neurological or brain/spinal conditions
  27. Sepsis
  28. Shock
  29. Transfer from an acute care setting
  30. Requiring mechanical ventilation

We were all trained in medical school that the history and physical examination was all about our diagnostic impression and medical management. But the H&P is additionally an integral part of the documentation game. In the documentation game, the physicians are the players for the hospital and the physician gets more points for the more secondary diagnoses he or she documents. The winner is the hospital that documents that its patients are really, really sick and then discharges them alive.

October 29, 2016

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

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