In this article, we discuss the benefits of coding and case management (CM) collaboration – in particular, the value of CM documentation.
By no means is this going to be an article about how case management should be cross-trained to learn coding. However, we believe there is value in coding professionals being able to engage in discussions with case management regarding the role of case management documentation in the coding process. Specifically, we want to emphasize how clear documentation on patient dispositions and social determinants of health (SDoH) risk factors can greatly enhance record integrity. As we have discussed in previous articles and broadcasts, there is no better way for coding to gain insight into and accurately capture Z-codes than by leveraging the descriptive documentation provided by case management in their initial assessments and ongoing progress notes related to patient involvement, including SDoH risk factors during hospitalization and their impact on the disposition plan.
The subsequent vital piece of information provided by Case Management (CM) pertains to the Post-Acute Care Transfer (PACT) policy. This policy, established by the Centers for Medicare & Medicaid Services (CMS), applies specifically to certain Medicare Severity Diagnosis-Related Groups (MS-DRGs) listed in Table 5 of the annual releases within the Inpatient Prospective Payment System (IPPS) final rule. Its purpose is to potentially modify payments in cases where a patient is transferred to a post-acute care setting before the expected geometric mean length of stay (GMLOS) associated with their respective DRG.
In essence, when a patient is discharged or transferred to a designated post-acute setting or service prior to meeting the GMLOS, the payment structure shifts to a per-diem rate. This rate is determined by dividing the MS-DRG rate by the GMLOS for the reduced number of days.
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has historically scrutinized coding practices and, in several instances, including the most recent evaluation in 2021, identified instances where hospitals received overpayments due to incorrect reporting of post-acute locations and/or services.
This underscores the significance of CM documentation. The ultimate disposition of the patient not only influences the level of specificity required by the coding team but also affects the reimbursement for the patient’s hospitalization. The list of post-acute locations includes:
- Transfers to psychiatric hospitals, cancer hospitals, or children’s hospitals.
- Admissions to inpatient rehab facilities.
- Stays in long-term acute-care hospitals.
- Residences in skilled nursing facilities.
- Commencement of home healthcare within three days of discharge (excluding services that resume due to the hospitalization).
- Discharge to home with hospice, either at home or in a facility.
For example, if a patient is discharged to their existing nursing home, CM may note “discharge home to facility X.” However, the coder must discern whether the patient is merely returning to their long-term care facility or if they are expected to receive skilled nursing services at that facility. Another scenario arises when a patient is discharged home with home health services, but the CM’s documentation does not specify the start date of these services. The hospital may miss out on reimbursement opportunities if the services commence more than three days after hospital discharge. Additionally, if the home health services are a resumption of care unrelated to the inpatient hospitalization, the hospital may unnecessarily forfeit some of its financial reimbursement.
Case Managers may not fully grasp the significance of their documentation, particularly concerning its impact on hospital reimbursement and record accuracy. This presents an excellent opportunity for coding professionals to collaborate with both new and experienced Case Managers. Together, they can review existing documentation practices and discuss the coding team’s needs to ensure precise documentation of each patient’s social risk factors affecting hospitalization, as well as the post-acute plan influencing disposition codes for financial implications and record integrity.