How Can Case Management Provide Support for Coding?

Last week I talked about the greater integration needed between clinical documentation integrity (CDI) and utilization review (UR), and with the nudge of Laurie Johnson, today I thought I would 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, I think there is value in coding being able to discuss with CM the role case management documentation plays in the coding process – and specifically, how clear documentation on patient dispositions and social determinants of health (SDoH) risk factors will help with record integrity. As I have talked about in previous articles and broadcasts, what better way for coding to clarify and capture Z-codes than from the descriptive documentation CM provides in their initial assessment and ongoing progress notes related to the involvement of patients, including SDoH risk factors of the hospitalization and their impact on the disposition plan?

The next most important information from CM is the post-acute care transfer (PACT) policy. The PACT policy by the Centers for Medicare & Medicaid Services (CMS) applies to specific Medicare Severity Diagnosis-Related Groups (MS-DRGs) rolled out in Table 5 of the annual releases for the Inpatient Prospective Payment System (IPPS) final rule to potentially adjust payment if the patient transferred to a post-acute care setting prior to the expected geometric mean length of stay (GMLOS) for each DRG. At a high level, if a patient is discharged or transferred to one of the specific post-acute settings and/or services prior to the GMLOS, the payment is adjusted to a per-diem rate that is calculated by dividing the MS-DRG rate by the GMLOS for those fewer days.

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has historically reviewed miscoding practices, and on several occasions, most recently in 2021, identified overpayments by hospitals that inappropriately reported post-acute locations and/or services.

This is where CM documentation is so important, because the final disposition of the patient not only impacts the required specificity for the coding team, but also the reimbursement for the patient’s hospitalization. The post-acute locations listed include (See the most recent MLN for specific details.):

• Acute transfers to psychiatric hospitals, cancer hospitals, or children’s hospitals;
• Inpatient rehab facilities;
• Long-term acute-care hospitals;
• Skilled nursing facilities;
• Home healthcare beginning within three days of discharge (not a resumption of services related to the hospitalization); and
• Home with hospice, at home or in a facility. 

So, for instance, if a patient is discharged to their existing nursing home, the CM may list “discharge home to facility X;” however, the coder will need to discern if that patient is just returning to their long-term care facility or whether they are expected to receive skilled nursing services at that facility. Another example is when the patient is discharged home with home health services, but the CM documentation does not specify the start date of those services. The hospital will miss reimbursement opportunities if the patient’s start date of services was greater than three days post-hospital discharge. Additionally, if the home health services were a resumption of care and not related to the inpatient hospitalization, the hospital could be unnecessarily giving up some of their financial reimbursement. 

CMs may not be aware of the value of their documentation, particularly for what is means of hospital reimbursement and record integrity. This is a great opportunity for coding to sit down with new and existing CMs to review their existing documentation and discuss the needs from the coding side to make sure the CMs are accurately documenting each patient’s social risk factors that are impacting the hospitalization – and the post-acute plan that is impacting the disposition codes for financial impact and record integrity.