Supportive inpatient documentation
As part of the RAC team and carrying the responsibility for the enjoyable RAC appeals, I am working on ideas to try to improve areas of weakness. My question is regarding documentation to support the inpatient stay. Our UR nurses will leave a note for the physicians letting them know the inpatient/observation status and los/time parameters. What I am finding during dicussions is that many physicians don't know what supportive inpatient documentation truly is; therefore the documentation has historically been weak. Do any of you support UR by querying for supportive inpatient documentation? If so, what tips do you provide to the physicians and what sources are you using? Also, by helping in this role, has it impaired your CDI relationship with physicians or helped in any way? Thanks so much.
Comments
We support UR by querying for the diagnosis that meets medical necessity for IP admission based on their complete evaluation (after study). We note that conditions must be present on admission to be the PDx, and then we coach them that any treatment plan they implement needs to have a diagnostic indication. We mention the criteria for a reportable condition, and then ask them to reinforce the patients' need for a physician's ongoing medical investigation and decision-making in each day's documentation. Why does the patient need to be an IP rather than an OP or OBS on today's date? Are there co-morbid conditions that increase the patient's risk of adverse outcomes, and please document what those risk factors are to support severity of illness.