Health Information Management

Q&A: Carrying forward documentation from the patient's past medical history

CDI Strategies, August 28, 2014

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Q: If a patient has hypertensive heart disease or cerebrovascular accident (CVA) with hemiparesis in his or her past medical history which has not been brought forward in the patient’s medical record for their current inpatient stay, can the coders assign a code for that condition or does it need to be brought forward by the physical? 

 

For example, would the physician need to document in the physician assessment that the patient had left-sided hemiparesis?

A: The documentation of the hemiparesis would need to be brought forward to the current record. The coders cannot assign codes based on documentation from a previous record. Review the current record closely for any clinical indicators that would prompt a query. For example, the nursing functional assessment within the admission assessment may demonstrate a weakness or paresis. If physical therapy is involved, the therapists’ documentation may provide a clinical indicator to support the query. If such indicators are present, use them to formulate your query.

If the hemiparesis is listed in the past medical history of the history and physical as part of the current patient encounter you may still need to query the provider. Physicians often describe conditions using the wording “history of” which can be quite vague, since it could mean either a history of a condition that has resolved or one which still remains present.

Due to this very confusion (and frustration on both sides) coders often do not assign a code based on documentation of a past medical history.

Again, review the record for any clues that the condition still exists, as well if it meets the definition of a reportable condition—i.e., did the condition require clinical evaluation, therapeutic treatment, diagnostic workup, extend the length of that particular patient’s hospital stay during this encounter, or increase nursing care and/or monitoring?

Lastly, in the case of the hemiparesis and CVA also query for the linkage of the hemiparesis (if found to be present) with the old CVA. This will allow the hemiparesis to be coded as a late effect of the CVA.

Editor’s Note: CDI Boot Camp Instructor Laurie Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.

 

 



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