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Lee M. Duke, MD
Editor-in-Chief
(717) 544-5145
lmduke@lghealth.org

Mary Beth Schweigert
Managing Editor
Corporate Communications Specialist
(717) 544-5093

MSchweigert2@lghealth.org


 
Healthcare Professionals / Progress Notes / Quality/Risk Management / Bridging the gap between clinical documentation and coding

 
Bridging the gap between clinical documentation and coding
8/9/2013

By Adele King, RHIA, Manager, Clinical Coding

 

Clinical coding is never a favorite topic with physicians, but its importance is increasing daily. Proper coding is essential for high scores on physician reports cards, important in value based purchasing arrangements, and ultimately, should lead to timely and correct reimbursement for physicians. Progress Notes asked Adele King, RHIA, Manager of Clinical Coding, to provide the Medical Staff with some best practice guidelines to assist the LGH Clinical Coding Team. 

 

Clinical documentation accurately reflects the condition and treatment of a patient. When practitioners provide the clinical rationale for each diagnosis and procedure involved, the severity of each patient and clinical condition will be appropriately captured.

 

Clinical code assignments are solely based upon the physician documentation throughout the record. Although coding language is based on medical terminology, they are not the same. Our professional coders must follow strict regulatory guidelines issued by CMS and code only what the physician documents. The coder is not allowed to make any assumptions regarding patient status. Our goal is to close the gap between physician documentation and coding.

 

The “physician query” is a tool clinical coders use to clarify clinical documentation for appropriate code assignment after discharge. In this day of audit and denial, it helps to establish a diagnosis which more accurately reflects the patient’s Severity of Illness (SOI) and Risk of Mortality (ROM). Since all diagnoses are factored into the patient’s SOI/ROM, the more complete the documentation, the better the medical record can reflect the patient’s true medical condition.

 

If you are a physician documenting the care of your patient within the EPIC EMR, we need your help. 

 

HIM coding will send you a coding query when the health record documentation:

  • Is conflicting, imprecise, incomplete, illegible, ambiguous or inconsistent
  • Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
  • Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
  • Provides a diagnosis without underlying clinical validation
  • Is unclear for present-on-admission indicator assignment

The HIM Clinical coding area will send a coding query to your EPIC In Basket. Once you have opened your In Basket, coding queries will be in your Coding Query folder.

 

In summary:

  • Document all acute and chronic diagnoses that were evaluated and/or treated in progress notes, H&P, consults, operative reports and the discharge summary.
  • Attending physician should carry forward all diagnoses pertinent to the admission in the discharge summary, even if resolved at time of discharge.
  • Respond to all physician coding queries in your In Basket. If you need assistance, please call HIM Coding: Adele King, RHIA, Manager, Clinical Coding, 544-2708; Cindy Biechler, CCS, Clinical Coding Coordinator, 544-4922; Kathy Leaman, CCS, Coding Liaison, 544-4674.
 
 

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