Tip: Focus on integrity of the medical record, not coding language

If a diagnosis such as acute blood loss anemia is unclear, it’s probably unclear to coding staff as well. In these situations, ask the physician what he or she thinks rather than digging for a Coding Clinic reference or the ICD-9-CM tabular index, Krauss advises.

 

Keep your question focused on the benefit to the physician. If you focus on integrity, the record will stand on its own and withstand RAC and other audit scrutiny, he says. “The Latin term is Res Ipsa Loquitur: The thing speaks for itself,” he says.

 

“Integrity means that the record shows the patient’s acuity, medical necessity, clinical judgment, the amount of work performed, medical decision making, and the nature of the presenting problem,” Krauss says. “As CDI specialists we’re not coding, we’re documenting for acuity and severity and the clinical judgment of the physician.”

 

For example, if a physician documents “respiratory distress and COPD exacerbation” for a critically ill patient he treated for nearly two hours, a simple written query for acute respiratory failure may not suffice, Krauss explains. Take the time to tell the physician that he or she has not captured the terminology necessary to reflect his or her complex medical decision making and time spent with the patient, which are necessary components of reporting a critical care E/M code. In the future he or she will likely remember to document acute respiratory failure.

 

Stress Res Ipsa Loquitur from day one of the admission. Don’t ignore ED documentation, the H&P or the progress notes, Krauss says. Attending physicians will often carry over diagnoses documented by an ED physician, so if you don’t clarify the up-front documentation you could be setting up negative patterns.