Health Information Management

Don’t jump to conclusions about documentation

JustCoding News: Inpatient, March 28, 2012

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by Robert S. Gold, MD

These days, documentation improvement and compliance are at the forefront of coders' minds. To reference a cliché, coders must watch their Ps and Qs when coding records. A "p" may look like a "b," or what appears to be a "q" is really a "d." In some cases, coders are led completely astray by bad data and physician documentation that isn't entirely accurate.

Whatever the reason, coders must be careful when reviewing documentation to ensure compliant coding. Coders should always look at the larger clinical picture—not just a laboratory result or change in vital sign that's documented in the medical record.


Ponder this question. Is a hemoglobin level that's fewer than 10 grams per deciliter (g/dL) always anemia? Or is the patient's hemoglobin low because of volume overload? Is the patient functionally anemic due to hemodilution, and will the condition resolve once the fluid volume is reduced? Surely, the patient doesn't have acute blood loss anemia when no blood loss is present.

Similarly, other serum electrolytes may be altered by fluid volume in the vascular space. Identifying the patient's defect is crucial. Don't conclude that there is an excess or deficiency of sodium or potassium without knowing what else is happening. The patient's heart will continue to react to high serum levels of potassium, and the brain will continue to swell with low levels of sodium. The levels may be relative rather than absolute.

Acute kidney injury

Ponder this question. Does a patient with a creatinine of 4.2 mg/dL truly have acute renal failure or acute kidney injury (AKI), or could it be that after workup and volume repletion the patient's creatinine remains at or around 4 mg/dL and the patient actually has a progression of chronic kidney disease instead?

The Acute Kidney Injury Network's definition of AKI includes variance in the creatinine level over a 24-hour period for patients whose fluid has been repleted. This means that if a physician concludes that the patient has AKI when presenting to the hospital, coders should consider inquiring whether the diagnosis should be changed. If so, ask the physician to document the reason (e.g., "What I originally thought was AKI turned out to be progression to stage 4 chronic kidney disease.").

Congestive heart failure

Ponder this question. Is a patient with a brain natriuretic peptide (BNP) level of 500 in acute congestive heart failure all the time, or could it be that the patient has a very hypertrophied heart or is in chronic renal failure and has a falsely elevated BNP level?

There may be some other reason why the patient has an elevated BNP. Patients with advanced renal disease take considerably longer to excrete some proteins. Something that caused the release of small amounts of BNP a few days ago but is now gone may lead the patient to have a persistently elevated BNP level. Is the patient currently symptomatic? Are the symptoms consistent with the patient's heart failure, or is there another real cause of the shortness of breath?

Myocardial infarction

Troponin I levels can be elevated above a laboratory's normal values, and this may not indicate that the patient has suffered myocardial infarction or myocardial necrosis at all—regardless of whether it's due to obstruction or demand causes. Patients with hypertrophic cardiomyopathy, chronic kidney disease, consistent bradycardia, and a myriad of other causes can have a persistent elevation of troponin level in the absence of overt ischemic heart disease. Some elevations of troponin are associated with myocardial necrosis and some are not associated with the condition.


Consider the following scenario. A patient has a fever due to exposure on a football field on a very warm day. The patient also has a tachycardia due to atrial fibrillation with rapid ventricular response as well as leukocytosis due to an injection of steroids for his arthritic shoulder. Does this patient have sepsis just because he meets three of the four criteria of systemic inflammatory response syndrome (SIRS)?

Too many cases are inappropriately identified as sepsis when a patient's manifestations of abnormal vital signs or laboratory tests have other origins. When coders inappropriately report sepsis, this yields poor data quality. Inappropriate physician documentation negatively affects everyone on the team who is trying to treat the patient.

Critical Care Medicine 2003, Vol. 31, No. 4—a journal published by the Society of Critical Care Medicine—updates criteria for sepsis. It emphasizes that physicians can be misled by the following:

  • High cardiac output that is often found following major surgical procedures or multiple trauma 
  • Hypotension that may be due to acute left ventricular failure secondary to heart attack, hemorrhage, or the adverse effect of beta blockers
  • Diffuse intravascular coagulopathy that may in fact be drug-induced

Regardless of whether a patient meets certain SIRS criteria or has organ failure consistent with sepsis or severe sepsis, physicians must only check off findings attributed directly to the infectious process. Just because the abnormality is present does not mean that a severe infectious process caused it.

The article also emphasizes that physicians must clinically assess whether patients are septic before reaching this conclusion based solely on laboratory values and vital signs.

Ventilator management

Is every patient intentionally maintained on a ventilator after an arduous surgical procedure in acute respiratory failure because the arterial pH is under 7.30 and the pCO2 is over 55? Or, more appropriately, does the patient need ventilator management instead?

Reversal from anesthesia leading to extubation after a surgical procedure is included in the payment for the operation itself. Physicians managing critical care areas shouldn't bill separately for it. If a patient is intentionally maintained for longer than the usual time for specific reasons, ventilator management may be billed. However, postoperative elective maintenance on a ventilator does not denote acute respiratory failure unless some other condition supervened or the patient had the condition prior to surgery.

Closing thoughts

Be cautious of quick conclusions based on a variance in laboratory results or vital signs. Review documentation in the record, collect all of the critical thinking elements before drafting a query, and encourage the medical staff to exercise clinical judgment to validate whether they ruled out conditions originally considered. Documentation must clearly show physicians' progression of thought and how they reach any clinical conclusions.

Editor’s note: This article was originally published in the March issue of Briefings on Coding Compliance Strategies. Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician clinical documentation improvement programs. E-mail questions to him at

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