Over the years it has been a standard practice of coders only to code from physician documentation. This has been a longstanding practice that has affected many hospitals negatively at one time or another.

In the late 1980s, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) began to look at how accounts were coded, and how aggressively, during the coding of pneumonia (utilizing code assignment, patient demographics, and hospital type, i.e., teaching, rural, urban, etc.).

As stated within the report, titled Simple Pneumonia and Pleurisy, there were errors related to misspecification of the physician leading to an incorrect diagnosis being assigned. For example, in some cases, bronchitis-asthma should have been assigned as the principal diagnosis instead of pneumonia. 

Over time, throughout the 1990s and into the 2000s, despite some progress this has remained an issue. The Hospital Payment and Monitoring Compliance Work provided coders with some guidance related to their role in coding and clinical relationships. 

  • The workbook states that “one effective method to achieve a greater level of training is to use clinicians from your facility to present classes on new surgical or diagnostic procedures, various clinical disease processes, and/or how certain surgical instruments are utilized (Bowman 2007).” This type of training can serve to educate both the coders and the clinicians. You should ask the coders to list, prior to the training, any clinical questions that impact coding on the topic to be presented. This helps the presenter know what to cover and increases his or her understanding of the relationship of clinical documentation to coding. The questions also can point out areas where improved physician documentation is needed.

Not only have coders been encouraged to query, but clinical documentation improvement has been introduced as an added step in coding to ensure accuracy and quality in the codes assigned. To better meet the demands of coding and clear up confusion with code assignment, querying the physician has been recommended and is currently widely practiced. The American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS) published a practice brief in February 2013 (http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050018.hcsp?dDocName=bok1_050018) to further assist coders and clinical documentation specialists on how and when to query when there is a question related to coding assignment due to conflicting and ambiguous documentation. They have gone on to encourage facilities to incorporate an escalation policy within their coding process when conflicts arise related to the diagnosis given and the clinical indications within the medical record.

Coders and clinical documentation specialists have continued to struggle with clinical relationships to code assignment, and this has been evident to the Centers for Medicare & Medicaid Services (CMS). This struggle has led to DRG validation reviews that include clinical validation of not only the codes assigned, but also of the clinical support of those codes throughout the medical record. These audits look beyond the simple documentation within the medical record to what clinical indicators are present in the form of vital signs, labs, tests, procedures, medications, and other assessments.

It is important for us to keep in mind that appealing denials is an option. We must utilize the medical record, symptoms, conditions, and treatment of each patient, as well as understanding of the clinical manifestations of a disease process, to assist auditors in understanding the reasons such appeals are filed.

Common diagnoses that the Recovery Auditors (RACs), Medicare Administrative Contractors (MACs), and other auditors are focusing on currently include:

Sepsis, pneumonia, acute renal failure, metabolic issues, toxic encephalopathy, respiratory failure, and malnutrition, just to name a few.

About the Author

Sharon Easterling is president and CEO of Recovery Analytics.

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