Ask, 'What's up, Doc?'

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Ask, 'What's up, Doc?'
Ask, 'What's up, Doc?'

By Ken Adams, M.D., Chief Operating Officer, Skilled Rehab Specialists

As an administrator, have you critiqued your medical director's notes? As the compliance director, have you asked, “Dr. Smith, I don't think you have justified medical necessity for your last visit”? As a skilled nursing facility appeal writer, have you pointed out to Dr. Smith that her last four notes were the same?

Well, guess what? That day is here. Long-term care administrators cannot bury their heads in the sand and think someone else will take care of this issue.

The California RAC demonstration targeted inpatient rehabilitation facilities and skilled nursing facilities and taught us a lot. The main thing it pointed out was that the physician note justifying medical necessity is critical.

As a physician, I used to be annoyed when non-physicians critiqued my work. I would mutter, “Get an M.D; then let's chat.” But an internal review of physicians' notes done by non-physicians is what needs to occur. If a chart gets requested by a RAC, MAC, MIC or Office of Inspector General auditor, a non-physician will be reviewing the chart.
A denied chart with recoupment is 18 months without payment. It may cost you more to get your money back than you have lost. Denials are a nightmare.

As the administrator, you need to develop an internal review process. Take a small, 5% to 10% monthly sampling of charts from each of the admitting physicians. Does the H&P give an explanation of the hospital stay, why the patient was referred to your facility and what will be addressed from a medical and rehab standpoint that could not be accomplished in a lower level of care?  Or, does the H&P just rehash the hospital stay and conclude with “Patient transferred to our facility on 9/10/09 for continued medical supervision”?

Do daily notes justify medical necessity or do they say, “Patient with no complaints. Vital signs stable. PE unchanged. Continue current care”? Does it read as if the physician did nothing but peek in the door and say hi? If the reviewer cannot figure out from the physician's note why the patient was in your facility, you have a problem.

Let's say after reviewing 15 to 20 charts, you find that there is a problem with medical necessity. How are you going to approach your physician and offer them constructive feedback?

The first step is understanding the “why” and then explaining it. For example, a patient complains of urinary frequency. The physician orders a UA that comes back negative. The physician decides to refer the patient to urology as an outpatient for possible benign prostatic hypertrophy. The only thing documented is the UA order. But the physician has made three medical decisions that help justify medical necessity. He heard a complaint, ran through a differential diagnosis of causes, picked the top one, ordered a lab test to confirm it, used the results to make a decision on the use of antibiotics, and made a decision on severity that postponed the urology referral.

No documentation was done because physicians often think what they do is common sense, but physicians with common sense will not be reviewing the charts. Physicians complain about increased documentation bogging them down and making them unable to see all their patients, but truthfully, all the physician needs to write in the plan is: “freq – UA neg, will refer to urology as outpt.”

The next step is the “WCS,” or worst-case scenario. This patient had a total knee replacement. The physician notes cellulitis, starts Keflex, and the symptoms resolve.  Keflex is the only order documented.

The doctor has just saved the Medicare system $40,000. How? She noticed an infection that could have spread to the bloodstream and seeded the implanted hardware. The surgeon would have to remove the hardware in one surgery and implant a spacer and antibiotic beads and give six weeks of IV antibiotics. The surgeon would have to implant another prosthesis.  These two surgeries and six weeks of IV antibiotics, plus more rehab, easily totals $40,000. I am not exaggerating; this happens.  Document this: “cellulitis – abx's started, multiple operations avoided.”

Documentation needs to show that if your facility was not taking such great care, the patient might have deteriorated at home.

Re-educating your physician may take a while. Provide good examples and suggestions rather than constantly criticizing them for what they omit. Consider a physician-only electronic medical record that prompts for medical necessity.

Physicians documenting well (and legibly) will help a facility overturn denials.  It is the administrator's responsibility to point out the issues, set expectations, and continue reviewing to ensure implementation.
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