Guest post: Exploring the importance of best practices for EHRs, coding guidelines, and queries

by Crystal Stalter, CDIP, CCS-P, CPC

What is a best practice? Who or what defines it? We hear it talked about all the time, but what does it really mean, and whom does it apply to?

The Merriam-Webster dictionary defines “best practice” as a noun meaning “a procedure that has been shown by research and experience to produce optimal results and that is established or proposed as a standard suitable for widespread adoption.”

In the HIM/CDI/coding world, best practices can stem from information issued by established sources such as AHIMA, ACDIS, AAPC, CMS, AHA, the ICD-10-CM/PCS guidelines, or even our own hospital or employer handbooks. We can look to industry standards that even newer HIM, CDI, and coding employees are aware of. Some best practices have been taught to us in textbooks or by the supervisors or managers in our departments, and many are well known among our peers. Let’s explore a few best practices and assess their importance.

Electronic health records

One of the hottest topics of discussion related to best practices is the copy-and-paste functionality of the electronic health record (EHR). With this technology now widespread in the industry, is it ever okay to copy something from a previous encounter into a new one?

This raises a question about the legitimacy of the information being recorded. For example, a physician copies and pastes a medication list from a patient’s previous visit into a new encounter for that patient. The provider most likely intends to update the list with any dosage changes, additions, or deletions, but what if the provider gets distracted or simply forgets to complete the update? Even though there’s no malicious intent behind this omission, it’s easy enough for it to happen.

The same holds true for a physical exam or a review of systems, especially in EHRs where free-text is used and not checkboxes or prompts. Copying and pasting also raises the question of whether the most accurate diagnosis is being recorded. If the information is identical from encounter to encounter, it becomes harder to demonstrate medical necessity to the insurance company responsible for paying the facility’s claims.

Although copying and pasting is common, it is best practice. Many hospitals and institutions ban it and many software programs either provide an alert when something is copied from another record or prohibit the function altogether. Physicians have their hands full, but we can bring a regularly occurring problem with documentation to their attention while still respecting their time.

Coding guidelines

Another example of a best practice is following the ICD-10-CM Official Guidelines for Coding and Reporting: When coding, first seek the code in the Alphabetic Index, but then use the Tabular List to apply the correct diagnosis code for the condition. Even seasoned coders don’t always adhere to this guideline, especially when they have committed codes to memory.

Why is such a seemingly easy instruction considered a best practice? Every year, new ICD-10-CM codes become available, and with them comes a whole new set of instructions for their application. For example, code first, use additional code, and Excludes1 and Excludes2 notes are published at the beginning of each new heading in the ICD-10-CM book. These new instructions can apply to older codes as well.

If a coder is only using the Alphabetic Index to look up a code, it is easy to miss those added instructional notes. This may create a medical necessity or other denial, resulting in precious time and manpower lost and unnecessary delays in payment. It is wise to get into the habit of looking up codes in the Tabular List so as to capture any additional information necessary to properly apply a code to a claim.

Querying

Is there a best practice when writing a query? AHIMA and ACDIS have both published   multiple articles and guidelines on the topic. AHIMA defines a query as “a provider communication tool used concurrently or retrospectively to obtain documentation clarification.”

A query should contain clinical information from the patient’s chart to clarify the question to the provider. The query should not be leading, but rather give the physician the opportunity to document based on his or her own interpretation of the information provided.

Each hospital has its own policy regarding the formal placement of the query in the chart and whether it becomes a permanent part of the patient record. Per AHIMA, if the hospital policy is to retain query documentation, legal council should be consulted for guidance regarding retention of queries, either in the patient’s legal health record or elsewhere.

Summary

We’ve explored some best practices followed by HIM, coding professionals, and the industry as a whole. There are others not mentioned that are equally as important and applicable. Remember the definition of a best practice: a procedure proven to produce optimal results that should be followed as often and fully as possible. We must follow these practices—there is too much at risk for us not to.

Editor’s note:  Stalter is the CDI manager for M*Modal in Pittsburgh. She has more than 30 years of experience in the healthcare industry, with most of her focus on coding, compliance, and physician documentation. Contact her at crystal.stalter@mmodal.com. Advice given is general. Opinions expressed are that of the author and do not represent HCPro or ACDIS. This article originally appeared in JustCoding.