Over the past couple of days, I read charts for patients who were sick. One gentleman had a fistula connecting his rectum to his bladder and he became septic and he was very lucky to be discharged from the hospital alive. He had a catheter and a surgical incision and therapy was ordered because his sepsis followed by surgery left him weak and debilitated. My client was very aggressive in restoring this gentleman to his previous level of health and he was discharged with all goals met after one episode. Another patient had an abscessed breast status post partial mastectomy that wouldn’t heal and during the first half of the episode, it was packed daily and during the latter half, she received negative pressure therapy. Again, my client magically convinced the wound to heal and the patient was discharged prior to the end of episode.

The claims for both of these patients and others would have been denied because my client and referring physicians failed to ensure that the physician documented HOW the patient’s condition affected them.

Regardless of the lead in phrase or question, physicians and nurse practitioners are answering, ‘what and why?’ In the examples above, the documentation read something to the effect that the patient needed skilled nursing for dressing changes and the patient required therapy to improve strength.

A reasonable person might assume that patients who require therapy to improve strength are weak. It should go without saying that patients requiring wound care have wounds.

But ADRs for claims are not being read by reasonable people. Your documentation is not being read by somebody who can use simple reasoning skills to deduce that a patient who has orders to pack a wound to the breast has a large gaping hole in their breast.

These omissions are simple – in fact they are too simple. The physician assumes that pretty much everyone knows that a gaping hole to a breast leaves a person open to infection and causes pain. When the document is reviewed in the agency, it is reviewed with the same understanding with which it was written.

If you do not address the 3 letter word that gets you paid there is a 4 letter word suitable for when you are denied.

The next time that you are reviewing a face-to-face encounter document, see how it compares to the examples below.

Examples:

• Pt began new medications with narrow safety margins. Side effects include dizziness and fainting putting patient at risk for injuries from falls and accidents.
• Pt has complicated surgical wound that is at high risk for infection and is located under the breast where the patient cannot visualize without potentially opening the wound.
• Pt has residual shortness of breath from pneumonia and profound weakness from extended bedrest in the hospital.
• Pt has elevated A1C and glucometer records show fluctuating blood sugars. Pt at high risk for renal complications if sugar doesn’t normalize.
• Pt is unable to ambulate s/p hip replacement without risk of displacing prosthetic hip. Anticoagulant therapy places patient at high risk for injuries and bleeding.

If you are overwhelmed with denials, check out this face-to-face inservice offered by Haydel Consulting Services.