Tip: Strengthen physician documentation of problematic diagnoses
CDI Strategies, February 7, 2008
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Following are some examples of how you can provide physician education on specific diagnoses:
- Call upon physicians to better document the character, underlying causes, complications, and severity using ICD-9-CM language. For example, in order to get decompensated congestive heart failure to count as a major complication/comorbidity (MCC), physicians must clearly state that it is acute as well as document whether it is systolic or diastolic heart failure. Stating one without the other will result in a CC only.
- Ask physicians to clearly document the underlying mechanisms of certain manifestations. For example, if a patient has hyperkalemia as the result of spironolactone, the physician needs to document the state of hypoaldosteronism. Similarly, if a patient has delirium due to narcotics, the coder or documentation specialist must ask the physician to document to what extent this is a toxic encephalopathy.
(The above is an excerpt from The MS-DRG Training Handbook, published by HCPro, Inc.)
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