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C linical Documentation Bridging the Gap. Karen Allen, RHIT September 26, 2009. Coding, profiling & compliance documentation requires specificity in DIAGNOSTIC terms. Physician Documentation is received in CLINICAL terms.

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Clinical DocumentationBridging the Gap

Karen Allen, RHIT

September 26, 2009

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Coding, profiling & compliance documentation requires specificity in DIAGNOSTIC terms

Physician Documentation is received in CLINICAL terms

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A Concurrent Clinical Documentation Program creates a bridge to help close the gap

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Issues Impacting Quality Data

•Incomplete Documentation

•Understating Complexity (both Severity of Illness and Risk of Mortality)

•Incorrect or Incomplete Coding

•Sequencing of Coded Data

•Poor Quality Care

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Severity of Illness

Many hospitals believe their patient population is “sicker” than

their competitors. However, their coded data does not show it.

The only way Medicare (and public reporting) “knows” their patients

are sicker is by the “severity” of their patients. This can only be

translated by diagnoses and procedure codes.

To be able to code all diagnoses in order to capture severity,

all diagnoses reportedmust be documented by the physician.

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Physician Documentation

If it’s not documented by the physician, it didn’t happen!

In coding, there is no deviation from this principle.

The coder cannot code a diagnosis, condition or procedure if it is not documented by the physician nor can the coder infer the acuity or chronicity of a diagnosis.

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Reporting of “Other” Diagnoses

For reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring at least one of the following:

• Clinically evaluated

• Therapeutically treated

• Diagnostic procedures

• Extends hospital length of stay by at least 1 day

• Increases nursing care and/or monitoring

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Coding of “Possible”, “Probable”

Inpatient cases:

Code these conditions as though they exist – applies to hospital setting only

If condition is ruled out, it may not be coded

Outpatient cases:

Must code signs/symptoms, not the suspected condition

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Major CC’s (partial list)

•Acute MI

•Acute renal failure

• Acute respiratory failure

• Acute systolic/diastolic heart failure

• Chronic Kidney Disease stage IV


• Decubitus ulcer – specified

sites, stage III or greater

• End stage renal disease

• Metabolic encephalopathy

• Pneumonia

• Septicemia

• Severe protein calorie


• V-fib (if patient lives)

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CC’s (partial list)


• Alkalosis

• Malnutrition

• Acute blood loss anemia

• Pancytopenia

• Drug induced delirium

• Rheumatic Heart Failure

• Unstable Angina

• Atrial Flutter

• Hemoptysis


• Acute exacerbation of COPD

• Pleural effusion

• Iatrogenic pneumothorax

• Ileus

• UTI (acute)

• Cellulitis

• Bacteremia

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Non-CC’s (partial list)

•CKD Stage I-III

•Seizure Disorder

•Angina (413.9)

•Atrial Fibrillation


•Chronic Blood Loss Anemia




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General Medicine

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General Surgery

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Nephrology / Urology

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Present on Admit (POA) Reporting

•All claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to a law or regulation mandating collection of present on admission information.

• POA indicator is based not only on the conditions known at the time of admission, but also include those conditions that were clearly present, but not diagnosed, until after the admission took place.

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What Are The POA Guidelines?

Supplemental to the ICD-9-CM Official Guidelines for Coding and Reporting

• Developed to facilitate the assignment of the Present on Admission (POA) indicator for each diagnosis and external cause of injury code reported on claim forms (UB-04 and 837 Institutional).

• Guidelines are not intended to provide guidance on when a condition should be coded, but rather, how to apply the POA indicator to the final set of diagnosis codes that have been assigned in accordance with Sections I, II, and III of the official coding guidelines.

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POA Reporting Guidelines

Present on admission is defined as:

• Present at the time the order for the inpatient admission occurs.

• Conditions that develop during an outpatient encounter, including ED, observation, or outpatient surgery, are considered as present on admission.

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POA Documentation

• Complete, accurate and consistent physician documentation is necessary

–If documentation is incomplete, conflicting, or vague then the physician must be queried for clarification

• Documentation from any physician involved in the care and treatment of the patient may be used to support the POA indicator

– May include any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis

– Determination as to whether a condition is present on admission may not be obtained from a non-physician documenter (e.g., nurse)

• It is not necessary for the physician to explicitly document whether a condition is present on admission in order to appropriately assign the POA indicator

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Physician Queries

A query is a question posed to the physician to obtain additional clarifying documentation in order to appropriately assign a diagnosis or procedure code

Queries can be concurrent, retrospective and/or post-bill

Query responses can be documented in the Progress Notes, the Discharge Summary or on a query form if it is kept as part of the permanent record

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Physician Queries

Must be:

• Clinically based

• Fact driven

• Concise and to the point

• Not leading

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Physician Queries

When to Query

Physicians should be queried whenever there is conflicting, ambiguous, or incomplete information in the health record regarding any significant reportable condition or procedure.

When Not to Query

Queries should not be used to question a provider’s clinical judgment, but rather to clarify documentation

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Leading Queries

  • Dr. Smith—Based on your documentation, this patient has anemia and was transfused 2 units of blood. Also, there was a 10 point drop in hematocrit following surgery. Please document “Acute Blood Loss Anemia,” as this patient clearly meets the clinical criteria for this diagnosis.

  • Dr. Jones—This patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission. Please document “Chronic Respiratory Failure.”

    No clinical data is given and no documentation option other than the specific diagnosis given

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Correct Written Queries

▪Dr. Smith—In your progress note on 6/20, you documented anemia and ordered transfusion of 2 units of blood. Also, according to the lab work done on xx/xx, the patient had a 10 point drop in hematocrit following surgery. Based on these indications, please document, in the discharge summary, the type of anemia you were treating.

▪Dr. Jones—This patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission. Based on these indications, please indicate if you were treating one of the following diagnoses:

(Then give a choice of appropriate diagnoses)

In these examples, the physician has clinical information and possible choices

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Physician Queries

The physician query process:

Improves the quality of documentation for complete and accurate coding, clinical data capture, compliance and optimum/appropriate reimbursement

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In Summary…..

Having a clinical documentation program is the way to ensure complete and accurate documentation in the medical record to reflect the patient’s true severity of illness

Overall goal is Accuracy!

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