With new rules and codes constantly changing, it's hard to know if your organization is up to date. At BookZurman, we believe in transparency and shedding as much light as possible onto the healthcare IT space, including data quality issues. That's why we're sharing three golden rules from our nationally-recognized coding experts to help your organization document and code more effectively and efficiently.
Rule #1: Document possible diagnoses and symptoms for accurate coding.
Did you know that symptom codes show low Severity of Illness (SOI)? If documentation states that a symptom is attributed to a differential diagnosis code, only the symptom can be coded -- not any of the diagnosis codes.
For example, "abdominal pain due to pancreatitis vs. cholecystitis" codes to abdominal pain. You could instead consider “possible acute pancreatitis v. possible acute cholecystitis causing abdominal pain.” Then, it would code to either pancreatitis or cholecystitis. By documenting this way, it's easier to demonstrate that your patient is as sick on paper as in the bed.
Rule #2: Document all diagnoses, even possible and suspected, for inclusion in mortality risk calculations.
Centers for Medicare & Medicaid Services (CMS) and Care Science (Premier QualityAdvisor) mortality risk models only include diagnoses that are Present on Admission (POA). It's imperative to document all diagnoses, including possible, probable, likely and suspected diagnoses in your history and physical (H&P) so they are included in the mortality risk calculation.
Diagnoses that greatly increase the risk of mortality in Premier’s model include:
- Encounter for Palliative Care (Z51.5)
- Are you managing symptoms for your patient with a terminal illness?
- Nausea, vomiting and/or pain control? Document it!
- Failure to Thrive
- Do Not Resuscitate (DNR)
- Sepsis
- Malnutrition (mild, moderate or severe)
Also, if you're asked to clarify if any conditions were POA, it's important to respond since this is part of risk calculations as well.
Rule #3: Don't downgrade condition severity.
Unintentionally downgrading the severity of a patient’s clinical condition in the medical record could lead to insurance company denial opportunities. It's also important to document all diagnoses in the patient's discharge summary. If hospitals aren't appropriately reimbursed, it will be increasingly difficult to take care of patients. Compare the examples below:
Incorrect documentation
- Patient initially admitted to the ICU with diagnoses of "Sepsis due to Pneumonia" and “Acute Respiratory Failure.”
- When patient is stable for transfer to the floor, the hospitalist who assumed the patient’s care only documented “Pneumonia” and stated shortness of breath has resolved.
- Insurance company argues that "Sepsis" and "Acute Respiratory Failure" were “ruled out” since they were no longer propagated throughout the remainder of the hospitalization – meaning they should not have been coded.
Correct documentation
- Sepsis, due to pneumonia – resolved
- Acute Respiratory Failure, due to pneumonia – resolved
- Pneumonia – continue current antibiotic regimen
Schedule a training
Through clinical document improvement (CDI), we can help improve data quality at your organization which, in turn, can help improve overall performance and patient care. As an objective advisory and implementation team, our certified clinical documentation specialists can educate your staff with a customized, on-site training program. Dr. Timothy Brundage, MD, CCDS, a nationally recognized CDI expert, believes that “our greatest accomplishment continues to be helping hospitals understand how to improve efficiencies through quality data inputs and capture."
Through our standards and interoperability work, data quality is just one way that BookZurman bridges the gap between healthcare and technology for a better patient experience. Contact us for deeper insights on how coding correctly can help improve the effectiveness of your organization. Our customized on-site training provides:
- Team education on coding best practices
- Implementation support for your team
- Quality of care metric improvements
- Insights to help maintain or increase your budget
Let us help you become a data quality leader by contacting us for custom, on-site training. Together, we can help empower caregivers to transform the future of healthcare – one patient at a time.
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