Health Information Management

Pay-Per-View: Improve accuracy with clinically-minded coding

APCs Insider, April 13, 2007

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Coders are well-versed in the intricacies of the ICD-9-CM Manual, Coding Clinic advice, and the coding guidelines. Unfortunately, this is only half of the battle. The other half lies in applying these guidelines to real-world documentation-which can often be ambiguous.

Coming changes, such as the present-on-admission (POA) indicator and severity-based DRGs, mean that the clinical aspect of coding will be even more essential. Enhance your clinical thinking skills now and improve your query process to avoid problems later.

In the case of the POA indicator, for example, physicians don't actually have to document that the condition was "present on admission" for you to be able to assign a POA indicator. In many cases, accurate POA assignment will depend on your ability to parse the clinical documentation. "Physicians don't have to write POA-and they're not going to," says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, a Wisconsin-based consultant. "We have enough trouble getting them to write the diagnosis. They give us a bunch of signs, 'rule out' symptoms, etc."

Click HERE to read more. Briefings on Coding Compliance Strategies subscribers have free access via their online subscriptions.

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