Health Information Management

Thorough documentation review helps ensure accurate principal diagnoses

HIM-HIPAA Insider, August 20, 2012

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Clear and consistent documentation makes a coder’s job much easier, and it improves data integrity. Who wouldn’t want this?

Specific documentation also offers numerous benefits, among them the greater likelihood of correctly assigning principal diagnosis codes, which drive MS-DRG assignment and payment.

Ideally, documentation of each patient encounter should include the following:

  • Reason for the encounter
  • Patient’s relevant history, physical examination ­findings, and prior diagnostic test results
  • Patient assessment, clinical impression, or diagnosis
  • Plan for care
  • Date of the encounter
  • Identity of the observer

However, documentation is effective only if ­coders take time to review it. Coders must review the ­entire ­record—not just the discharge summary—before ­assigning a principal diagnosis, says Gloryanne ­Bryant, RHIA, CCS, CDIP, CCDS, an AHIMA-approved ICD-10-CM/PCS trainer in California with more than 30 years of HIM experience. This includes a ­thorough review of progress notes, the ­history and physical, ­consultations, physician orders, and any other reports designed to capture diagnostic information.

“It really causes me grief when coding staff say, ‘I didn’t have time to read anything but the discharge summary,’ ” says Bryant. “That would be a compliance risk. We don’t want to hear that.”

Coding managers and supervisors must find a delicate balance between establishing productivity standards that meet hospital expectations while also allowing coders flexibility to review all documentation to assign the most accurate codes, she says.

Editor’s note: Read more in the August issue of Briefings on Coding Compliance Strategies.

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