Highmark to pay more for better diagnostic documentation

Highmark Inc., a Blues plan serving Pennsylvania, Delaware and West Virginia, is giving physicians a financial incentive to increase documentation of diagnostic codes in the electronic health record of patients insured under Medicare Advantage or health insurance exchange programs.

Too often, physicians enter a core diagnosis following a visit but do not also reference previous diagnoses that a patient has had, Highmark contends. That makes it more difficult for physicians to understand who their most complex patients are and provide follow-up care.

Insufficient coding also makes it more difficult for Highmark to identify these patients and make sure they are getting the care they need, says Amy Fahrenkopf, MD, vice president and medical director at Highmark. The insurer has set aside as much as $5.5 million to reimburse physicians who more comprehensively code complex patients.

Physicians returning accurate forms, including forms that have just one diagnosis because it is the only one, will get an additional $125 per completed form. Physicians returning 60 percent of these forms will get another $25 per patient, and those returning 75 percent of forms will get another $15.

Highmark will not pay physicians to add codes that don’t exist, Fahrenkopf emphasizes. The goal is that, over time, physicians will be consistently giving multiple pertinent codes; not only a new diagnosis if appropriate, but also past diagnoses that remain. The higher payments will help offset investments that physician practices likely will need to make to change workflows, maybe hire another staff member to prep the patient charts for the physician and put the documentation form on top of the chart, and make changes in the EHR.

For instance, many EHRs have a function, often not used, that scans for diagnoses entered previously that have not been entered for a patient in the current year, then sends an alert to the physician of the past diagnoses and asks if any of those remain be entered. A staff member can query the EHR and do this task, but the physician still must verify past diagnoses before charting documentation on a new visit and sign the form sent by Highmark.

Even though Highmark will be paying participating physicians more for better documentation of diagnoses, the insurer can get more money from government health plans for the treatment of complex cases if Highmark can provide evidence that the cases are complex, which could be done with more accurate reporting of diagnoses. Consequently, Highmark could reduce insurance premium costs because it is getting paid enough to manage complex patients, Fahrenkopf says. “The cost of these patients doesn’t get passed down to anyone else.”