Busy ED Environment Breeds Documentation Lapses

By Elizabeth S. Goar for Becker’s Hospital Review

When it comes to emergency department activities, documentation doesn’t jump immediately to mind. Far from it, in fact, but that doesn’t mean it’s not vital to an organization’s financial well-being.

With emergency department (ED) visits climbing steadily, along with case acuity and complexity, it’s a service line whose influence on a hospital’s revenue cycle is also on the rise. That makes it a natural target for clinical documentation improvement (CDI) strategies that can shore up support for appropriate reimbursement levels and avoid leaving any ED-generated dollars on the table.

“Most of our patients who come in for admission come in through the ED—about 80%. So, you can imagine that if we didn’t pay attention to [documentation in] that environment, we might be missing a few things,” says Tinu Tadese, MD, FACHE, CHFP, vice president of clinical informatics with Lake Health in Concord Township, Ohio. “There are a lot of lost charges [in the ED] which, of course, means lost revenues. It’s the largest portal of entry, so anything not done there affects the rest of the admission, especially documentation and, subsequently, revenue generation.”

While COVID-19 maintains a stranglehold on most health care organizations’ revenue cycles, any missed billing opportunities are being felt more acutely than ever. Consider the results of a recent American Hospital Association study which found that hospitals had cancelled 67% of their ED-related services in the wake of the pandemic. Those cancelations contributed significantly to the loss of $161.4 billion in hospital services over just four months in 2020.

Furthermore, while the ED is the gateway to the hospital for most patients, including transfers, it is considered an outpatient setting unless the patient is admitted to the hospital. At that point, “services rendered in the ED are rolled into the inpatient payment for Medicare and some other payers,” says Cheryl Ericson, MS, RN, CCDS, CDIP, clinical program manager with Iodine Software.

ED documentation must demonstrate medical necessity and establish diagnoses associated with the inpatient admission. Therefore, while the role of the ED is to stabilize patients and determine whether admission is warranted, staff are also treating conditions that may or may not resolve prior to admission. When they do, those conditions are not reported on the inpatient claim.

“However, ED providers are often very cautious and often fail to make diagnoses, instead often documenting signs and symptoms that they correlate to a variety of differential diagnoses,” Ericson says. “Once the patient is stabilized by the ED, they may not exhibit the same severity of signs and symptoms, causing many ongoing diagnoses to be lost.”

Ambiguity and Reluctance

A good example of this conundrum is when a patient shows up at the ED with signs of acute respiratory failure. The patient is stabilized in the ED, but the associated diagnoses may not be documented. When the determination is made to admit the patient, the symptoms are less severe “so the admitting physician may not make the correlation to the patient’s presentation and document the diagnosis of acute respiratory failure,” Ericson says.

“ED providers are often very ambiguous in their documentation since it is often early in the disease course, but attending physicians are often reluctant to use findings from the ED to support applicable diagnoses because the patient has been stabilized at the time of their evaluation,” she continues, noting that ED documentation should also help support medical necessity by demonstrating that the patient’s condition requires care that can be offered only in the inpatient setting or that extends beyond at least two midnights for Medicare patients.

“ED documentation should clearly outline the risks associated with patient discharge as well as reflect all patient comorbid conditions that contribute to the complexity of the patient’s acute condition, which may require additional work-up before a diagnosis can be made.”

Blame for documentation shortfalls doesn’t lie solely with the ED or admitting physicians, however. According to Timothy Brundage, MD, CCDS, CEO and medical director of Brundage Group, which provides end-to-end CDI and revenue cycle solutions, it’s not uncommon for coders to omit ED documentation when coding the inpatient record unless it is repeated by the attending physician.

Doing so, he says, overlooks documentation that captures illness when the patient is typically sickest—and the point at which the encounter begins.

“The ED is where all clinical documentation starts. If a patient is admitted to full inpatient status, then all the diagnoses from the emergency room should be documented as part of the hospital record. Usually, the patient improves [between] the emergency room and hospitalization, so documentation must be captured in the ED because that is where the patient has the highest severity of illness,” Brundage says. “Documentation is important and it’s often the last thing an ED physician wants to do, but it is paramount to accurately reflect the illness of the patient.”

Another reason comprehensive and accurate ED documentation is so important comes from June Bronnert, MHI, RHIA, CCS, CCS-P, senior director of global clinical services for IMO: Services provided in the ED utilize hospital resources just as they do elsewhere in the facility.

“Emergency department documentation holds the same universal saying as documentation across health care: If it was not documented, it was not done,” she says. “If a service is considered ‘not done,’ then charges for the service are inappropriate. If resources were used, but a facility is unable to charge and subsequently bill, their revenue is greatly impacted.”

A Unique Environment

Tadese, who presented “Optimizing Clinical Documentation in the Emergency Department to Maximize Revenue Capture” at the AHIMA20 Virtual Conference, notes that ED documentation quality is impacted by “the fact that it’s a very fast-paced environment and when patients come in, the emphasis isn’t on documentation. We know [documentation] is the basis of the revenues the hospital generates, but in the ED’s fast pace, the focus is on care delivery, not documentation.”

What’s more, Ericson says, because of that “high-volume, fast-paced environment where any delay in patient care can result in death, ED providers often don’t have the time to interact with CDI professionals or respond to queries.”

Furthermore, as an outpatient setting, ED services are reimbursed differently than those provided in the inpatient setting. Couple that with the fact that fewer than one-half of the patients seen in the ED are ultimately admitted, and it creates an environment wherein ED providers “are likely unfamiliar and disinterested in learning about inpatient documentation requirements. It is already cumbersome for providers to understand the different documentation and billing requirements for hospital and professional billing,” Ericson says.

Depending on its size and location, the ED may be staffed with board-certified physicians who work exclusively in EDs, or it may be staffed by physicians with other specialty backgrounds who are moonlighting in the ED. “Providers who are not full-time ED physicians will likely be even less familiar with documentation and billing issues related to ED services,” Ericson notes.

The specter of liability issues also hangs heavy over the heads of ED physicians, says Brundage, who is a diplomate of the American Board of Internal Medicine and cochair of the CDI committee for the American College of Physician Advisors. ED physicians must document for multiple audiences—patients, professional services billing, hospital billing, and medical legal protections—and must be “cognizant of all of them. A hospital doctor like me is not under quite the level of scrutiny that emergency doctors are, such as threats around failure to diagnose. To mitigate this risk, ED physicians may document symptoms instead of diagnoses, even though diagnoses code more effectively track severity of illness and risk of mortality.”

He adds, “ED doctors use symptom-based instead of diagnosis-based language, and that’s a challenge for the revenue cycle team.”

The solution, according to Brundage, is to encourage ED physicians to make diagnoses based on symptoms using words such as “likely” or “suspected.” For example, abdominal pain can be diagnosed as “likely” or “suspected” acute appendicitis, which allows for assigning the appropriate diagnosis-related group without forcing the ED physician to declare the final diagnosis before it is confirmed.

Another issue is the tricky situations confronting ED physicians. For example, if a patient presents with a urinary tract infection (UTI), it most likely can be managed in the outpatient setting. However, if the UTI causes acute kidney injury, that patient is much sicker and likely requires inpatient care. Linking those two diagnoses together—organ dysfunction due to a UTI—meets criteria to diagnose sepsis.

“So, if the diagnosis is a UTI with acute kidney injury and if the patient’s creatinine is greater than two, it’s sepsis, which carries a 10% risk of mortality,” Brundage says.

The sepsis diagnosis would trigger the SEP-1 Core Measure protocol. “Thus, linking those conditions together is critically important, not only to show the true clinical needs of the patient … but also to document the sepsis in order to properly capture the diagnose,” Brundage says.

Tadese shares that an audit of Lake Health’s ED documentation to determine which charges were commonly missed found that just a handful of repeated missed documentation opportunities quickly added up to millions of dollars in lost revenue. For example, lack of documentation around smoking cessation, which is reimbursable, was a frequent culprit. With upwards of 60% of patients in the ED being smokers, failing to document counseling on how to quit or failing to document the time spent on the discussion is an expensive oversight.

Similarly, ED providers often neglect to document the depth or extent of the lacerations they repair, which “can be the difference between being reimbursed $50 or $350 per repair,” Tadese says.

Verbal orders are another problem area. In the ED, a physician often will call out the order which the nurse completes. “But what happens many times—because of the highly pressurized environment—is that no one goes back to put that order in the chart,” Tadese says. “Many times, the nurse will document the task, but it can’t be billed because there was no documentation of the ordering of that task.”

The range of treatments a physician will see on any given day in the ED creates a constant level of uncertainty that can impact documentation—which is exacerbated by constant interruptions and the short time available to fully document the patient’s ED experience, according to IMO Vice President of Global Clinical Services Steven Rube, MD, FAMIA. This extends into documenting a detailed patient history, which can be complicated by the patient’s condition.

“Patients experiencing life-threatening conditions may be unable to communicate details of their medical history,” Rube says. “Even when patients convey their medical history, they may not convey specific details important for diagnostic code assignment and therefore the details are not documented. For example, a specific stage of chronic kidney failure may be relayed in a variety of ways depending upon the patient.”

Reaching CDI Maturity

Improving ED documentation requires physician buy-in, consensus on the ultimate goal of the process, and the necessary resources. It’s a delicate balance made more challenging by the 24/7, fast-paced nature of emergency services.

Noting that the best approach to ED CDI “remains one of the million-dollar questions,” Ericson points out that a go-to resource in the inpatient setting—technology—is a much trickier issue due to the setting’s volume and diversity of care. For example, templates by condition tend to be less effective in the ED because of the wide variety of conditions coming through the doors. Plus, physicians don’t always have a definitive diagnosis “so a chest pain complaint can become a condition related to the gastrointestinal system,” Ericson says.

“In the old days, the provider could not shift from a chest pain workup template to a gastritis workup template as their differential diagnoses narrowed,” she notes, suggesting that technology should support these types of changes as they occur so the documentation needed for each condition updates as the provider reaches a definitive diagnosis. “There is a gap between clinical decision-making tools and documentation tools. Often, you must have a diagnosis before you can use a clinical decision-making tool. You can only get support on how to treat pneumonia once the diagnosis of pneumonia is made, but ED providers often don’t have definitive diagnoses.

“ED CDI efforts are one of the most immature areas of CDI because there is a lack of consensus about whether the goal is supporting inpatient hospital reimbursement or outpatient hospital reimbursement—which makes it much more complex than any other area,” Ericson says.

The more traditional hours kept by CDI departments further complicates matters. The typical eight- to 10-hour day does not work in the round-the-clock emergency world. Without flexible staffing hours, there are bound to be times when a CDI specialist is needed to support ED documentation efforts but is not available.

“The more successful ED CDI programs are those that are supporting inpatient hospital billing by encouraging documentation of diagnoses, as supported by evidence, like acute respiratory failure, acute kidney injury, metabolic encephalopathy, poisoning, aspiration pneumonia, etc,” Ericson says. “There also has to be collaboration with the coding department because there is often disagreement about when a diagnosis is ‘resolved’ or ‘cured’ in the ED compared to an ongoing condition that was merely stabilized in the ED.”

Brundage recommends providing ED physicians with continuous feedback and meaningful education. Ideally, this is based on regular monitoring of documentation to identify and quickly address problem areas.

“The documentation review team should review records, query the physicians as needed, and, hopefully, escalate the need for feedback to the physician advisor,” Brundage says. “The physician advisor is the one to educate the ED physicians, either as a group in a team meeting or individually as needed.”

Tadese, who seconds the notion that education is vital to improving ED documentation, recommends an all-hands-on-deck approach that starts with an audit to set benchmarks. “The best thing to do is an external audit [and] benchmarking with organizations of the same size and with the same volume of ED usage. Those are the organizations you want to compare yourself to and, if they’re doing better, ask yourself why, investigate, and come up with a solution,” she says.

Then, bring together everyone—from the CFO and revenue cycle heads to clinical and ED leadership—to brainstorm on the root causes of documentation issues and possible solutions. Next, dive into training, which must be followed with regular audits.

Lake Health conducted quarterly audits and refresher training “until everything became routine,” Tadese says. “It takes a while for new processes and ways of thinking to stabilize. If you don’t keep checking … it’s going to go back to the same as it was.”

Those audits are particularly important when there is high turnover or frequent use of traveling nurses or physicians, she says, adding that “the best check is your revenues, which should increase significantly.”

Bronnert recommends meeting with ED clinical leadership to review the effectiveness of documentation practices. These meetings should be viewed as opportunities to collaborate with physicians on the development of best practices and the design of optimal workflows.

“One workflow example is diagnostic capture,” Bronnert says. “If providers can document clinically intuitive diagnoses in their normal course of work, the chances of capturing the most specific diagnosis known at the time increases.”