• E-mail
• Print
• RSS

Tip: Watch for "clinical perception" errors related to present on admission reporting, involve CDI specialists in education

CDI Strategies, March 6, 2008

Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!

Present on admission (POA) reporting errors are often the result of "clinical perception" errors, or coders who lack the clinical knowledge to assess a given admission and deduce from the record whether the patient's condition was truly POA, says DeAnne Bloomquist, RHIT, CCS, chief consultant for Mid-Continent Coding, Inc., in Overland Park, KS.
 
Consider the following scenario: A 40-year-old patient reports to the ED with a femoral fracture and is admitted. He is also an alcoholic. The coder incorrectly reports delirium tremens (DTs) as a diagnosis that was present on admission.
 
"The patient was not in DTs when he came in with a femoral fracture and went straight to the operating room--the patient did not go into DTs until four days into the stay," Bloomquist says. "I classify the types of coding errors I see into two categories: Coding guideline errors, and clinical perception errors. I consider [this case] to be a clinical perception error."
 
If coders in your hospital are experiencing similar problems, CDI specialists are a great candidate for providing education to HIM/coding staff and reducing POA reporting errors. "That's where the follow-up and education comes in with the audit process," Bloomquist says. "Sit down and teach them about the things you're finding--that's the only way they're going to learn."

Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!

• Comment
• E-mail to a Colleague
• Print
• RSS
• Archive

Comments