Unintended ICD-10 Consequences: Inadequate Clinical Documentation Can Negatively Impact Physician Profiles – ICD-10 Tuesdays

The following is a guest blog post by Minnette Terlep from Amphion Medical Solutions.
Minnette Terlep
Often lost in the overarching conversation surrounding the potential negatives of ICD-10 is the very real impact it could have on the selection of physicians and hospitals by health plans, MCOs and shared-risk organizations for participation in provider networks. To succeed, these organizations seek out providers with a strong track record of care that is both high quality and cost-efficient—which is where ICD-10 can hurt or help.

Physicians do not assign codes. They are, however, responsible for documenting at a level of specificity that allows the assignment of codes—the burden of which is exponentially higher under ICD-10. The coder can only assign codes matching the level of specificity supported by the documentation. If the assigned codes reflect a level of severity that is artificially low because of inadequate documentation, it can raise red flags for organizations who profile physicians.

That is because these organizations look not only at severity of illness and mortality rates, but also cost efficiency in providing care. If a physician appears to be over-utilizing resources based on the final assigned codes, it is very likely he or she will be considered a risk and excluded from the network.

For example, if a physician simply documents “pneumonia” as the principal diagnosis and the patient receives standard care for this simple pneumonia, the case will generally and appropriately assign to the lower weighted MS-DRG for community acquired pneumonia.  But what if the patient is actually diagnosed with a type of gram negative pneumonia that is fully supported by a positive culture? If the physician fails to document this more resource-intensive type of pneumonia so the significantly higher weighted MS-DRG can be assigned, then the patient’s days in the ICU and on the medical floor for continued care would not appear to be justified.

The difference in cost between the two scenarios is thousands of dollars, which is problematic on its own. However, it also presents ongoing challenges for the physician in the second scenario: Getting improperly tagged as a resource over-utilizer because, based on the codes and MS-DRG assignment, excessive care was provided. This could easily result in exclusion from a plan or participation in shared-risk initiatives.

We’ve been inundated with information on how clinical documentation must be significantly improved in advance of ICD-10 because of the impact under-coding can have on reimbursements and core measures performance. However, as illustrated in the pneumonia scenario, the potential impact on individual physicians runs deeper. When the highly detailed nature of ICD-10 is coupled with the growing emphasis on standardized care and quality over quantity, it spells potential financial and reputational ruin for physicians whose profile raises concerns about mortality rates and ability to provide cost effective care.

It may also impact the hospitals with which the physician is affiliated. Both can quickly find themselves locked out of networks and excluded from potentially lucrative shared-risk models. Exacerbating the potential impact is the growing (albeit slowly) emphasis patients place on identifying physicians and hospitals with high quality and outcomes rankings, both of which can be tainted by the specter of over-utilization.

While protecting a physician’s profile from the over-utilization category isn’t generally at the center of documentation improvement strategies in advance of ICD-10, there are ample reasons why it should be. So much of what we see and hear about the greater specificity required under ICD-10 is geared toward the impact DRG assignments will have on reimbursement, but in reality it can have far greater long-term financial and reputational repercussions.

Thus, identifying and correcting gaps and areas of weakness in clinical documentation will be beneficial not only for ensuring appropriate reimbursement levels and outcomes metrics reflecting true performance, but also to prevent unjust exclusion from provider networks.

Physicians and hospitals taking the time to analyze profiles to ensure they accurately reflect utilization rates, and to identify and correct documentation-related problem areas that may leave managed care and shared-risk organizations with the wrong impression, will find doors to participation will remain open—and benefit the bottom line.

Minnette Terlep, BS, RHIT, is vice president of business development and chief compliance officer for Amphion Medical Solutions. She can be reached at Minnette.Terlep@amphionmedical.com.

Check out all of our ICD-10 Tuesdays series of ICD-10 related blog posts.