Coding News You Can Use: Documentation Essentials

By Author: Nancy Rose
Total Articles: 53
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Documentation holes will cost your practice thousands of dollars in denied claims. Your top priority is getting top-notch clinical documentation for your inpatient coders. The latest coding news is that physician query and communication is now paramount, and not just important.

To be sure your payments are on track, keep a track of up-to-the-minute coding news and see how your hospital's policies and procedures address the following physician documentation discrepancies and issues:


Documentation mistake 1: If it is clear to the physician, it will be clear to the coders.

Physicians may assume that coders can get what they need by, for example, looking at lab values or other test results. But according to national coding guidelines, coding staff cannot code from lab values, and they cannot diagnose. Coders need the narrative terms required to support key diagnoses.

Under the new MS-DRG system, the reality is that we need a lot more specific and detailed verbiage in the medical record to support correct coding.

Documentation ...
... mistake 2: Someone else will fill in the blanks for you.

Don't let physicians pass the buck when it comes to proper documentation in the medical record. Coders can't just pluck support for their codes from anyone's notes in the chart. For example, information regarding malnutrition must come from the physician (or a physician assistant or clinical nurse specialist) - not from a dietitian.


Documentation mistake 3: Physicians drag their feet when coders' queries come their way.

This is a mistake - but not necessarily the physicians'. How physicians respond to queries for more information depends in large part on how knowledgeable they are regarding the coding process - and health information managers are responsible for securing that buy-in.


Don't put your practice at risk by staying behind the updates. Get the recent coding news, or your practice's revenue will suffer.