Health Information Management

What is good documentation?

HIM-HIPAA Insider, June 9, 2014

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We all know that ICD-10 codes will require more complete documentation. We’ve been telling physicians that, but maybe we’re not explaining it well or correctly.
What makes documentation better? It’s not the volume of the documentation. It’s the actual content of what the provider puts in the record.
For example, Eric is a diabetic patient with peripheral neuropathy. Dr. Jones documents “diabetes” in Eric’s medical record. In ICD-10-CM, we would default to E11.9 (Type 2 diabetes mellitus without complications).
Unfortunately, that code doesn’t really reflect Eric’s severity of illness. The code description states “without complications,” but Eric in fact does suffer from a diabetic complication. The physician didn’t document it, so we can’t code it.
If you work in an outpatient setting, E11.9 alone probably won’t support a high-level visit CPT code. And it’s definitely not going to support medical necessity for an inpatient admission.
However, if the physician documents “Type 2 diabetic with peripheral neuropathy,” we can report E11.43 (Type 2 diabetes mellitus with diabetic autonomic [poly]neuropathy). The physician added five words, but we coded a much more specific diagnosis.
If you have an EHR, find out whether you can add prompts to the system to require additional information. If the physician chooses “diabetes” from a drop-down menu, can you add a submenu that requires the physician to specify Type 1 or Type 2? Can you add a prompt asking if the patient has any associated conditions (such as renal failure) or other complications?
Maybe you can, maybe you can’t. It doesn’t hurt to ask.
We’re not asking physicians to write War and Peace for every patient (although some patients may require extensive documentation). The content of the documentation, the actual clinical information the physician includes, is much more important than volume of the documentation. If the physician writes an 18-page progress note for an inpatient with a diabetic foot ulcer, but doesn’t connect the diabetes to the ulcer or provide any information about the stage and site, you’re stuck reporting less specific codes.
Better documentation will benefit physicians and coders now and after the ICD-10 transition. Look for ways to help your physicians document better to make your own transition easier. Ambiguous, incomplete, or unclear documentation makes the coder’s job harder. The better the physician documentation, the easier it is to assign the correct code.
Use the extra time between now and ICD-10 implementation to convince your physicians of the value of better, clearer, concise documentation.
This article originally appeared on HCPro’s ICD-10 Trainer blog.

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