(Mobile, Ala.)—Major financial implications are at stake if healthcare facilities and physicians do not accurately record the health conditions of patients that are present on admission (POA), according to new regulations by the Centers for Medicare and Medicaid Services (CMS).

CMS is adjusting the logic for Diagnosis Related Group (DRG) assignment, including new methods for identifying patients who are severely ill (that is, have comorbid illnesses) and consequently warrant higher hospital reimbursement. To quality for this level of reimbursement, these secondary medical conditions must be identified and described in detail on the medical chart.

Recently-published research in the September 2007 Journal of Clinical Outcomes Management showed that concurrent coding utilizing electronic medical record technology can significantly increase the identification and documentation of these comorbid illnesses, which in turn increases the severity of illness and risk of mortality indexes used for reimbursement. The research, titled “Effect of Concurrent Computerized Documentation of Comorbid Conditions on the Risk of Mortality Index”, partially relied on coding technology from DocuSys, Inc., a leading anesthesia information management system (AIMS) and medication management system provider.

“The technology provided by DocuSys provides a detailed view of comorbid conditions currently not available with common paper documentation in use by most anesthesia clinicians,” said Dr. Jerry Stonemetz, Clinical Associate and Compliance Officer, Anesthesia & Critical Care Medicine, Johns Hopkins University. “This detail could significantly affect the data captured by most hospitals, resulting in improved reporting and documentation of comorbid conditions required by CMS and other organizations for reimbursement.”

Documentation of comorbid conditions is a primary element of the DocuSys coding module, which is an embedded component of the company’s AIMS application. This technology was developed specifically for anesthesiologists who traditionally see a large subset of hospital inpatients with varied medical conditions. It precisely captures a patient’s existing medical conditions while assigning ICD-9 diagnosis codes to them. In the study, concurrent coding using this technology increased severity of illness and risk of mortality ratings by 16 percent and 17 percent respectively.  

Accurate identification of comorbid conditions has been a challenge for healthcare providers that has only been recently addressed with technology, according to Dr. Peter Pronovost, Professor and Medical Director of the Center for Innovations in Quality Patient Care at Johns Hopkins Medical Institute and University School of Medicine. “Documenting comorbid conditions and consistent use of that data among healthcare providers has been challenging,” he said. “Technological solutions to assist with identification of comorbidity have numerous benefits that include developing medical care plans specific to each patient which improves the probability of receiving correct payment from CMS. Also, with patient safety and quality measure reporting currently at the forefront of the healthcare industry, precise documentation of each case has never been more important.” 

About DocuSys

DocuSys is a market-leading anesthesia information management system (AIMS) and medication management system provider, maximizing both the quality of care and return on investment in surgery. The system incorporates customizable decision support, professional fee capture, comorbid condition documentation and an intravenous medication management application, which uses barcoding and digital imaging to automate documentation, tracking and billing of medication. DocuSys’ modular design permits integration with existing hospital information systems, electronic drug dispensing cabinets, infusion pumps, physiologic monitors and other systems in those settings where intravenous medication delivery is key. www.docusys.net.