The American Hospital Association (AHA) cites regulatory friction as a driver of increasing healthcare costs within their Making Health Care More Affordable: A Blueprint to Lower Costs, Improve Access and Enhance Quality publication.
Specifically, it cites “unnecessary, outdated and redundant regulations, such as duplicative surveys and documentation requirements.” The same is true of many regulations that impact clinical documentation integrity (CDI), coding, and utilization review (UR) activities.
It is time to update the definition of the principal diagnosis to better reflect today’s complex inpatient population, modern documentation practices, team-based care delivery, and evolving reimbursement strategies. How often do we see two equally plausible principal diagnoses on admission?
How often does the reason for admission evolve by the second day in the hospital?
I tried to set the stage for this argument last week by discussing the changing inpatient population, which is becoming “sicker and more complex,” as the healthcare needs of less-acute patients can be met in the outpatient setting. A crucial element in establishing payment rates for the inpatient population is the principal diagnosis, which relies upon a definition that was established in 1980, prior to implementation of Diagnosis-Related Groups (DRGs) as a payment mechanism.
This update could occur in conjunction with an AHA recommendation to standardize insurance information and claims adjudication.
The Uniform Hospital Discharge Data Set (UHDDS) definition of the principal diagnosis as “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care” (Federal Register Vol. 50, No. 147) was created in 1980 and published in the Federal Register in 1985. This definition is a cornerstone of ICD-10-CM Official Guidelines for Coding and Reporting, to which adherence is required under the Health Insurance Portability and Accountability Act (HIPAA), a federal law.
In the days of paper admission orders, it was much easier for the CDI and coding professional to know what diagnosis occasioned the admission because the admitting physician would document “admit to (insert unit) for (insert diagnosis).” However, if the provider failed to document the reason for the admission, the patient population had fewer documented comorbidities or complications that competed for recognition as the principal diagnosis. In addition, only one physician, the admitting provider (who was also the attending), was responsible for their care, allowing for a more cohesive clinical story with linear progression.
In today’s inpatient hospital record, there is so much record bloat and extraneous documentation from multiple providers, intermixed with copied and pasted notes, that contradict updated findings, often making the health record a muddled mess. There is also pressure on CDI and coding professionals to clarify every diagnosis to its highest specificity, because it could directly or indirectly impact reimbursement.
Most of all, many electronic health records (EHRs) no longer require an admitting diagnosis to accompany the inpatient order. Although it may appear optional in practice, documentation of the admitting diagnosis is required for Medicare claims and under the Conditions of Participation (COPs).
Medicare also requires that the contents within the health record “contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services (42 CFR 482.24(c)).” The UHDDS definition, unchanged since 1980, still governs how we determine the principal diagnosis, even as Medicare COPs have evolved and documentation expectations have grown more complex.
Ironically, this section also includes requirements for the timing of the history and physical (H&P), patient examination, and assessments, all of which are closely monitored by a hospital’s health information department. Why is documentation of the admitting diagnosis not treated with the same importance as these other medical record elements, especially when it determines the basis for payment under the Medicare Severity Diagnosis Related Group (MS-DRG) methodology?
Beyond establishing the base MS-DRG, the principal diagnosis influences both coding and medical necessity audit vulnerability. It also defines quality cohorts for both hospital-level and provider-level metrics. A patient with acute hypoxic respiratory failure versus exacerbation of systolic heart failure present different medical necessity and quality profiles, which must be considered in addition to the impact on reimbursement. The principal diagnosis drives both hospital revenue and reputation.
At a minimum, the Centers for Medicare & Medicaid Services (CMS) and the Cooperating Parties should revisit the UHDDS definition and how it applies to code assignment. More meaningfully, the industry should consider requiring clinicians to explicitly document the condition ultimately responsible for the admission.
Coding guidelines emphasize that “a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.” Yet in practice, physicians are often absent from the determination of the principal diagnosis.
Even when suggested by coding guidelines, CDI and coding professionals may not query the attending physician when one or more diagnosis may meet the definition of a principal diagnosis. Also, the guideline begins with the phrase “in the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis.” Yes, coders are best suited to apply the Alphabetic Index, Tabular List, or other coding guideline that may direct sequencing, but who is best qualified to evaluate and determine the “circumstances of admission, diagnostic workup and/or therapy provided?”
Is that not the treating medical team, or at a minimum, a clinician or physician?
