We all know in clinical medicine that documentation is everything. Hence the old saying “If it’s not documented, then it didn’t happen.” This is particularly true outside of the clinical realm in the insurance world. Level of care is based on the clinical condition of the patient, how they present and how that meshes with the guidelines that are being used to determine the level.
Like anything else, if documentation does not support specific disease conditions, intensity of services, services being rendered or being considered, differential diagnosis, etc., that may adversely affect the level of care. What we sometimes see is a clear thought process happening between the emergency room physician, the admitting hospitalist, and the consultants, but we don’t necessarily see that documented clearly. This may end up adversely affecting reimbursement as the insurance company may not truly understand what was required to take care of a patient. Past medical history is important, in particular for patients with diabetes, coronary vascular disease, congestive heart failure, and COPD. We often run into cases where inpatient level of care is denied because the past medical history is not clearly documented.
For example, in a patient with diabetes, how well controlled is their diabetes? And does the documentation explain this. A hemoglobin A1C, for instance, even if it was done prior to the admission, needs to be included in the patient’s past medical history because that helps everybody understand how well the diabetes is being controlled.
Consider this question, if a patient comes in with chest pain or angina and has a significant cardiovascular history, do you think the insurance company should know what the patient’s baseline is? Do they need to know whether or not the patient takes nitroglycerin often or not at all? Have they had prior interventions? If so when were those interventions? How many interventions did they have? You get the idea; all of these things help paint a better picture to the insurance company about the risk level of a patient. Many times, once the insurance company understands the elevated risk due to the patient’s past medical history, they’re more likely to approve inpatient level of care.
Although most physicians document well, some are very focused on the care of the patient, which is necessary, however, they are not always focused on documentation. Many physicians are in-tune to this and understand the need to document everything. What all physicians need to understand is that documentation may not only have a direct negative impact on hospital reimbursement, but also on the care of the patient.
Complete documentation including a robust past medical history are things that, even if they’re not completely germane to the patient’s immediate issues, are important to include in the medical record.