Documentation for Acute Care

Chapter 1

Clinical Documentation and the Healthcare Delivery System

Introduction

• Colonial America– Public hospitals developed solely for the

purpose caring for the poor and isolating the sick

• 19th Century– Quality improvement efforts directed at

medical school training

Introduction – cont’d

• Early 20th century– Standardization of hospital care began

• Late 1940s– Hospital building boom– Modern surgical techniques– Antibiotics– Employers added health insurance coverage

to compensation packages

Introduction – cont’d

• 1965 Amendment to Social Security Act– Medicare: Primary payer for the healthcare

services provided to retired workers (and their spouses or surviving children)

– Medicaid: Pays for healthcare services provided to indigent individuals and their families who qualify for benefits.

Introduction – cont’d

• Late 20th century – modern healthcare, but at a cost– Americans have come to expect and demand

the most advanced medical care available.– United States spends more on healthcare

than any other industrialized nation.– Almost 44 million Americans have no health

insurance

Healthcare Providers and Facilities

• Physicians and physician’s assistants• Nurses and nurse practitioners• Psychologists and clinical social workers• Physical, respirator, and occupational therapists• Dentists and dental hygienists• Medical technologist and cytotechnologists• Patient care technicians and paramedics• Podiatrists and chiropractors

Healthcare Services

• Acute care • Ambulatory care• Behavioral health

care• Emergency and

trauma care

• Home health care • Hospice care• Long-term care• Rehabilitation care • Skilled nursing care -

also called subacute care

Trends in Healthcare Delivery

• Current system is a complex amalgam of payers, providers, and facilities that function more or less independently.

• In 2002, more than 15% of Americans had no health insurance coverage.

• Cost of healthcare services has grown at rate much faster than overall inflation.

Trends in Healthcare Delivery

• Most diagnostic services and noncritical therapeutic services have moved away from the acute care hospital setting.

• Many hospitals have merged with other general and specialty hospitals and subacute and ambulatory care providers to form integrated healthcare networks.

Hospital-based services

• Inpatient services provided in acute care hospital are reserved for the sickest patients and the most invasive medical procedures.

• Inpatient: An individual who receives healthcare services as well as room, board, and continuous nursing care in a hospital unit dedicated to providing around-the-clock patient care.

Hospital-based services

• Noninvasive diagnostic procedures, same-day surgery, chemotherapy, and radiation therapy are now routinely performed in separate ambulatory facilities or in the outpatient departments of acute care hospitals.

• Outpatient: An individual who receives healthcare services in a hospital-based clinic or department but who is not admitted to a dedicated acute care unit.

Continuum of Care

• The sum of all the healthcare services provided in all settings, from the least intensive and specialized (and the least expensive) to the most intensive and specialized (the most expensive).– Primary– Secondary– Tertiary

Primary Care

• Services generally provided by physicians working in private offices, group practices, private clinics, or community-based clinics.

• Family practice, pediatrics and general internal medicine physicians

• Nurse practitioners or physician assistants

Primary Care Services

• Preventative care

• Routine screening and laboratory tests

• Physical examinations

• Diagnosis and treatment of minor infectious illnesses

• Diagnosis and management services for chronic illnesses

• Diagnosis and treatment of minor injuries

Secondary Care

• The diagnostic and therapeutic services provided by medical specialists working in private offices, specialty group practices, private clinics, community-based clinics, and general and community hospitals.

• Medical or surgical specialty care

• Both office-based and hospital-based care

Tertiary Care

• The provision of highly specialized and advanced diagnostic and therapeutic services in inpatient and outpatient hospital settings.

• Usually provided by medical specialists working in large, urban hospitals and specialty clinics affiliated with nearby medical schools and universities.

Medical Necessity

• Will the services provided to a specific patient have a reasonable beneficial effect on his/her physical needs and quality of life at a specific point in his/her illness or life?

• An important consideration in modern reimbursement systems

• Driving force for complete and accurate clinical documentation.

How healthcare is reimbursed?

• Paid for by employers and provided to employees as part of their employment agreement:

1. Commercial health insurance plans

2. Blue Cross/Blue Shield plans (similar to commercial plans but structured as nonprofit entities)

3. Employer-based self-insurance plans funded directly by employers

How healthcare is reimbursed?

4. Government-sponsored health insurance programs

5. Commercial health insurance plans or Blue Cross/Blue Shield plans purchased by private individuals

6. Payments made directly to providers by healthcare consumers

Reimbursement Methods

• Retrospective payment systems – Based on the payment of fees charged according to the actual medical services provided.

• Traditional fee-for-service – Services paid for after they were provided and are based on a fee schedule.

Reimbursement Methods

• Managed fee-for-service – A negotiated discounted fee schedule with providers.

• Prospective reimbursement – A set fee for membership in a prepaid health plan and then all of the services the beneficiaries needed for the period of time are covered by their agreement

Managed Care

• Term used to describe several types of prepaid health plans that combine the delivery and financing components of healthcare.

• Health Maintenance Organizations (HMOs)

• Preferred Provider Organizations (PPOs)

Government-sponsored Prospective Payment Systems• Developed to control healthcare spending

• Began in the early 1980s

• Bases reimbursement on patient classification groups

Government-sponsored Prospective Payment Systems• Inpatient acute care – DRGs

• Physicians’ services – RBRVS

• Skilled nursing facilities – RUGs

• Outpatient Care – APCs

• Home Care – HHRGs

• Inpatient Rehabilitation - CMGs

Health Record

• Source of information to support reimbursement for services

• Complete, timely, and accurate clinical documentation – If it wasn’t documented, it didn’t happen

Chargemasters

• A database that maintains information the charges for services and the underlying costs associated with those services.

• Used to organize information on all of the goods and services the hospital provides to patients.

Chargemaster Information

• Charge dollar amount• Charge code• Item description• General ledger key• Revenue code• Activity date

• CPT/HCPCS code• Major insurance

charge code• Department code

numbers

Capitation

• Contract between healthcare facility and a HMO to provide services to its enrollees.

• HMO agrees to pay the facility a negotiated fee as payment in full for the services regardless of actual charges.

Government-Sponsored Health Programs• Medicare

• Medicaid

• TRICARE

• Civilian Health and Medical Program-Veterans Administration (CHAMPVA)

• Workers’ Compensation

Medicare Part A

• Implemented in 1966 for Social Security beneficiaries

• Largest single payer for healthcare services in the United States – Acute care services– Long-term care services– Home health care services– Hospice care services

Medicare Part B

• An optional supplemental medical insurance plan.– Emergency department services– Ambulatory surgery– Psychiatric care– Durable medical equipment– Occupational, physical, and speech therapy– Outpatient diagnostic/therapeutic services

Medicare Part C

• Also called Medicare+Choice• Individuals who qualify for Medicare Parts A and

B may choose Part C coverage as an alternative.

• Part C products include HMOs, private plans that choose to participate in the program, and medical savings accounts.– Long-term nursing care– Dental care– Eyeglasses and hearing aides– Self-administered prescription drugs

Medicare Prescription Drug Program• Set for implementation in 2006

• Will include:– Minimum monthly premiums – Significant deductibles and copayments

Medicaid

• Enacted in 1965 under Title XIX of the Social Security Act

• Contributes federal funds to the medical assistance programs operated by individual states.

Medicaid Services

• Inpatient hospital services• Outpatient hospital

services• Prenatal care• Vaccinations for children• Physicians’ services• Skilled nursing services

for over 21• Family planning

services/supplies• Rural health clinics

• Home health services• Lab and x-ray• Pediatric and family nurse

practitioners• Nurse-midwife• Ambulatory services• Early and periodic

screening and diagnostic/therapeutic services for children

Other Sources of Funding for Acute Care Services• City/County government operating public

hospitals

• State governments operating public hospitals

• Charitable foundations, religious orders, churches, and labor unions operate not-for-profit hospitals

Clinical Documentation in the Health Record depends on:• The profession and specialty training of

the healthcare provider

• The healthcare setting

• The type of healthcare service

Purposes of the health record:

• Ensuring the continuity of patient care among providers and along the continuum of care

• Providing a means for evaluating the outcomes, quality, and medical necessity of care

• Providing documentation to substantiate reimbursement claims

• Protecting the legal interests of patients, caregivers, and healthcare organizations

Purposes of the health record:

• Providing clinical data for biomedical research• Supporting professional education of physician,

nurses, and allied health professionals• Supporting the operational management of

healthcare organizations• Providing health services data for public health

planning and governmental policy making

Owners of the health record

• Legally, health records are considered the property of the healthcare provider that created them.

• Ethically, the personal information in each record still belongs to the patient.

• HIPAA established a consistent set of privacy and security rules for patient information.

Definition of the Health Record

• The legal health record

• Patient-identified source data

• Administrative data

• Derived data

The legal health record is:

• The official business record created at or for the healthcare organization.

• The portion of the health record that would be released upon request to parties outside of the organization.

Patient-Identifiable Source Data

• Data that are maintained in a separate database or location but are summarized in the legal health record in the form of clinical interpretations, notes, or other derivative reports.

Administrative Data

• Authorizations for release of information

• Birth and death certificates

• Patient identifiers

• Protocols, clinical pathways, practice guidelines, and other decision-support materials

Derived Data

• Information collected or summarized from health records in a form that does not include patient identifiers.

• Accreditation reports

• Public health records

• Statistical reports

• Anonymous patient data used for research purposes

Documentation Guidelines for Acute Care• Unique to the type of hospital

• Must take into account all accreditation, federal and state licensure requirement and regulations.

• Support reimbursement

• AHIMA’s General Guidelines for Inpatient Documentation

Future of Clinical Documentation for Acute Care• Electronic Health Record Systems

• EHR Functional Model

• Longitudinal Health Record

• Personal Health Record