Health Information Management

News: TrailBlazer probe highlights documentation disparity

CDI Strategies, September 2, 2011

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Out of 88 claims for MS-DRG 246 (percutaneous cardiovascular procedure with drug-eluting stent with MCC or 4+ vessels/stents with a length of stay less than or equal to two days) reviewed during a recent probe audit, TrailBlazer Health Enterprises, LCC, fully denied 65 of them, according to a recent notice released by the Medicare Administrative Contractor (Notice ID 14504).

TrailBlazer, the J4 Medicare Administrative Contractor for Texas, Oklahoma, Colorado, and New Mexico, conducted the probe after it identified DRG 246, “as a service that receives significant reimbursement from Medicare.” 
“As you take a few minutes to read the [notice], you will see several references to clinical documentation including lack of documentation reflecting complication or severity of illness warranting inpatient admission,” says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, an independent consultant based in Madison, WI.
According to the probe results, medical records reviewed did not include laboratory and diagnostic test results or physician interpretation of diagnostic tests. Furthermore the results indicate that documentation was lacking for complication or severity of illness, risk factors, or complications that could only be treated at an inpatient level of care.
“With this in mind, there certainly is ample opportunity for our profession to expand our thoughts and efforts to ‘holistically’ improve clinical documentation,” says Krauss.

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