Closing the Gap Between Case Managers and Coders
Guide to Senior Care Options & Patient Care Assisted / Alzheimer’s – Home Healthcare – Hospice – Home Care Senior Living - Skilled Nursing & Rehabilitation – Rehabilitation Hospital MOBILE AND DIGITAL AVALIABLE
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CONTENTS
Volume 2 Issue 1
Greater Atlanta
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There’s a communications gap between case managers and coders that generally reveals itself too late in the patienttransition process:
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ELIMINATE HARM ACROSS THE BOARD Days Since Last Readmission READMISSIONS PREVENTION:
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Conduct enhanced admission assessment of discharge needs and begin discharge planning at admission
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Conduct formal risk of readmission assessment; align interventions to patient’s needs and risk stratification level
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Perform accurate medication reconciliation at admission, at any change in level of care and at discharge
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Provide patient education that is culturally sensitive, incorporates health literacy concepts and includes information on diagnosis and symptom management, medications and post-discharge care needs
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Identify primary caregiver, if not the patient, and include him/her in education and discharge planning
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Use teach-back to validate patient and caregiver’s understanding
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Collaborate with post-acute care and community-based providers including skilled nursing facilities, rehabilitation facilities, long-term acute care hospitals, home care agencies, palliative care teams, hospice, medical homes, and pharmacists
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Before discharge, schedule follow-up medical appointments and post-discharge tests/labs; for patients without a primary care physician, work with health plans, Medicaid agencies and other safety-net programs to identify and link patient to a PCP
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Conduct post-discharge follow-up calls within 48 hours of discharge; reinforce components of after-hospital care plan using teach-back and identify any unmet needs, such as access to medication, transportation to follow-up appointments, etc.
Send discharge summary and after-hospital care plan to primary care provider within 24 to 48 hours of discharge
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Closing the Gap Between Case Managers & Coders As if case managers don’t have enough to do. There’s a communications gap between case managers and coders that generally reveals itself too late in the patient-transition process: after the patient’s been discharged and when an auditor is eyeing discrepancies to flag. Fixing that is like shutting the barn door after the horse is gone. Case managers, though, are well-positioned to eliminate that communications gap. After all, case managers have the information about the patient’s discharge status and all other facets of that discharge that can affect reimbursement: where the patient ultimately went, to what level of care and when the services started. Coders forced to rely on what the physician initially ordered for post-acute care may not have specifics about the actual PLEASE SAY; I FOUND YOU IN CASEMANAGEMENT SOCIALWORK
discharge. Case managers who facilitate the transition of care, however, do have that information and must ensure that coders get it too. Otherwise the wrong discharge codes entered in a patient’s claim for payment can result in financial or legal penalties. Or both.
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It’s Not a Turf War. It’s a Fight for What’s Right.
Yes, assigning a discharge code is the responsibility of coding professionals. Yet it’s case managers who know the details and appreciate the importance of clear documentation on the revenue cycle and other issues of post-acute care. But it’s not enough to know the facts: Case managers need to communicate to coders what they know and when, and that’s at the time of discharge. For example, it makes a difference in coding when a patient is transferred to a skilled nursing facility (SNF) for extended care for rehabilitation, or to custodial care or hospice. It also makes a difference if the medical record shows a referral was made to a SNF (Code 03) and the patient subsequently was discharged to a family member with no referral (Code 01). Discharge status codes are used for assignment of MS-DRGs, monitoring the post-acute transfer policy, tracking referral types, readmission analysis and tracking network usage and leakage, among other things. To assign the correct MS-DRG for a Medicare patient, the age, sex, discharge status, principal diagnosis, secondary diagnosis and procedures performed are reported. Notice that discharge status has equal weight with diagnosis and procedures; not everyone appreciates that. One way to improve the accuracy of coding is to increase awareness about its importance and to discuss it with coders and case managers. Ideally, that discussion is coupled with an electronic records system that captures in a structured workflow the most up-todate information, from start of care to level of care, that has an immediate and significant impact on getting claims processed without incident. Jackie Birmingham, RN, MS
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