Health Information Management

Documentation and query strategies for sepsis coding

HIM-HIPAA Insider, November 11, 2013

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Coding for sepsis is often easier said than done. Obstacles range from difficulty distinguishing between documentation for sepsis and related conditions to trouble with physician queries.

Accurate and ethical records should contain ­appropriate documentation that anyone can easily understand, including patients or lawyers, said Robert S. Gold, MD, founder of DCBA, Inc., a clinical documentation improvement consulting firm in Atlanta. Physician documentation that cannot be easily interpreted and coded can lead to inaccurate data, incorrect coding and billing, and sometimes legal action, he added.

Gold's sentiments align with the medical record documentation principles outlined by CMS and Trailblazer Health Enterprises, LLC. The principles stress the importance of complete and legible medical records..

The February 2013 "Guidelines for Achieving a Compliant Query Practice" set forth by AHIMA and ACDIS state that a query should be considered when documentation:

  • Is conflicting, imprecise, incomplete, illegible, ­ambiguous, or inconsistent
  • Describes clinical indicators unrelated to an underlying diagnosis
  • Includes clinical indicators, diagnostic evaluation, and/or treatment unrelated to a condition or procedure
  • Provides a diagnosis without clinical validation
  • Is unclear for present on admission indicator assignment

Editor’s note: Continue reading "Documentation and query strategies for sepsis coding" on the HCPro website. Subscribers to Medical Records Briefing have free access to this article in the November issue.

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