Clinical Documentation –Why We
Care
Shelley L. Oglesby, M.Ed, RHIT, CCS-P
Manager, Coding & Reimbursement
Nancy Ignatowicz RN, BS, MBA, CCDS Manager Clinical
Documentation
July 24, 2013 Surgical Residents Orientation
Significance of Documentation
Acuity / severity of illness
Risk of mortality, O:E
Pt walks out alive, the hospital’s profile improves when
comparing hospitals & outcomes.
QUALITY measures
Patient safety indicators
Physician profiles, research data & funding
Intensity of services provided => hospital receives the
appropriate reimbursement.
Academically sound note writing.
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Why Care?
Proper documentation ensures appropriate severity of
illness (SOI) and risk of mortality (ROM):
Substantiates Medical Necessity for
Appropriateness of admission/continued stay
Versus observation status or even outpatient
Truly reflects how complex your patient is,
how ill they are, and how likely they are to die
It’s the right thing to do
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CDI
Clinical Documentation Improvement Team
The role of the Clinical
Documentation Specialist (CDS)
RN’s review the medical record concurrently to
ensure treated diagnoses are documented with
specific terminology so the coder can code the
most appropriate codes for Severity of Illness
(SOI) & Risk of Mortality (ROM)
Clarifications are asked when an additional or
more specific diagnosis may be present but not
documented in verbiage that can be coded
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The role of the Coder
Coder reviews the medical record postdischarge to assign the most appropriate ICD
diagnosis(es) and procedure(s) codes to ensure
accurate Severity of Illness (SOI) & Risk of
Mortality (ROM) and appropriate MS-DRG
assignment
Clarifications are asked when an additional or
more specific diagnosis may be present but not
documented in verbiage that can be coded
Diagnoses should be based on a physicians clinical judgment. Examples are not all inclusive
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Common opportunities for clarification
Records indicate
-..Post surgical anemia…
-..Hypotensive, requires
vasopressors, tachycardia,
multiple fluid boluses…
-..Intubated for airway
protection…
-In PACU patient
unresponsive, desat to 88%
requiring reintubation…
Consider Documenting
Acute Surgical Blood Loss
Anemia
Shock and Type
Acute Respiratory Failure/
Acute Respiratory Distress
How to Avoid a Clarification/Query
With EVERY DIAGNOSIS consider:
Etiology
Severity
Type
Present or evolving on admission (POA)
Clinical manifestations
Treatment
Pathology findings
Valued Tips
1. Specify the diagnosis that best supports the principal
reason for the inpatient admission to the hospital
(condition established after study)
2. Use the following acceptable terms to describe
uncertain diagnoses:
Probable, suspected, likely, possible
Avoid terms such as “concern for” or “VS”
Diagnoses should be based on a physicians clinical judgment.
Valued Tips
3. Identify conditions/diagnoses that are present on
admission (POA status)present at the time the inpatient admission occurs,
includes conditions that develop during an outpatient
encounter (emergency room, observation, outpatient
surgery) that result in an inpatient admission
Diagnoses should be based on a physicians clinical judgment. Examples are not all inclusive
Valued Tips
4. List comorbid/complication diagnosis which are
defined as:
conditions that coexist at time of admission
conditions that develop subsequently
conditions that affect the treatment/care
conditions that impact the length of stay
Include chronic conditions such as hypertension, COPD
etc
Diagnoses should be based on a physicians clinical judgment. Examples are not all inclusive
Gaps in Documentation
UNABLE TO CODE
ACCEPTABLE TO CODE
Na 130 -> fluid restriction
Hyponatremia
Dirty UA -> antibiotics
Post surgical anemia, will
monitor/Blood loss-> PRBC
UTI
Acute Blood loss anemia due to
trauma/ruptured aneurysm
Elevated creatinine-> IVFs
AKI or ARF
LUL opacity -> Zosyn
LUL bacterial pneumonia
Flash pulmonary edema
Acute pulmonary edema
Avoid the TERM POST-OP
Gaps in Documentation
UNABLE TO CODE
Abdominal fluid
Dyspnea, SOB requiring
BiPap/high flow O2
NC/intubation
Hypotension,
vasopressors,
EBL,temp, tachycardia,
Tachypnea
ACCEPTABLE TO CODE
Abscess/ intraperitoneal
abscess/peritonitis
Acute respiratory distress
or acute respiratory failure
Consider shock and type
Examples
Documentation of ALL secondary diagnoses
present is how Severity of Illness (SOI) & Risk of
Mortality (ROM) is captured
Do you think Loyola patients are sicker than
patients in community hospitals??
Patients are only as critical / complex as their
documentation indicates
Inherent Diagnoses
Sigmoidectomy
Sigmoidectomy
PDx: Diverticulitis
Sigmoidectomy
RW
LOS
1.6361 5.0
PDx: Diverticulitis
Sigmoidectomy
Peritonitis present on
admission
SOI
ROM
RW
LOS
1
1
5.2599 14.9
SOI
ROM
2
1
With post op Ileus
2.5731 8.6
2
1
If Acute Kidney Injury added
If Acute Kidney Injury added
RW
LOS
2.5731 8.6
RW
LOS
5.2599 14.9
SOI
2
ROM
2
SOI
3
ROM
2
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Admitted with colon cancer
52 yo with esophageal cancer with left hemicolectomy
RW
LOS
SOI
ROM
1.6361
5.0
2
1
Documented: Stage 3 colon cancer
1.6361
5.0
2
1
With confirmation of path findings for positive lymphadenectomy:
lymph nodes positive for metastatic carcinoma
2.5731
8.6
2
2
Admitted for Lumbar Spinal Fusion
63 yo with chronic back pain s/p lumbar/sacral fusion T10 to S1 EBL 1000cc
RW
LOS
SOI
ROM
3.8783
3.6
1
1
Clinical: history of diastolic heart failure hold lasix
3.8783
3.6
2
2
Documented: overnight Pt hemodynamics unresponsive to fluid
resuscitation requiring pressors
3.8783
3.6
2
2
With complete documentation: Overnight Pt hemodynamics unresponsive
to fluid resuscitation requiring multiple pressors. Hypovolemic shock
6.5390
9.1
2
2
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Admitted for removal of renal mass/lesion
52 yo with enhancing lesion right kidney, suspicious for solid lesion
RW
LOS
SOI
ROM
1.3335
2.9
2
1
Clinical: history of atrial fibrillation
1.3335
2.9
2
1
Documented: underwent right robotic assisted retroperitoneal partial
nephrectomy without complication
1.3335
2.9
2
1
With complete documentation: Right renal cell carcinoma
1.4836
3.2
2
1
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Admitted with esophageal cancer
52 yo with esophageal cancer for surgical resection
RW
LOS
SOI
ROM
5.6118
15.4
3
2
Documented: celiac lymphadenectomy also performed
5.6118
15.4
3
2
With confirmation of path findings for lymphadenectomy: celiac lymph
nodes positive for metastatic carcinoma
5.6118
15.4
3
3
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Quality
Your notes get better from an academic
standpoint
Explains reason for admission/readmission
Explains mortality
Low SOI/ROM score could be explained from review of records
showing failure to document comorbidities
I.E. malnutrition, pre-op ileus, anxiety, obesity, Chronic systolic
CHF, CKD stage 3, Acute blood loss anemia due to liver laceration
from trauma, Shock, peritonitis, sepsis from pre-surgical rupture
diverticulum, Respiratory failure from pulmonary fibrosis, toxic
encephalopathy related to sepsis…
Present on admission (POA)
Define if condition was POA, evolving on admission/natural
progression of disease
LINK symptoms to diagnosis determined after further diagnostics
and evaluations
Inpatient Medical Record
History & Physical
Why inpatient admission necessary
Reason for inpatient surgical admission
Include diagnoses in assessment plan not just PMH
Progress Notes & Consultations
Link significance of findings/treatments (medications,
diagnostics) to diagnoses
Discharge Summary
Should include all diagnoses addressed during this
admission including chronic,resolved problems and any
pathological findings(including post discharge)
ICD-10
Lack of documentation is becoming a problem
for acceptance.
Wieste Venema
ICD-10- Prepare Now
For example, if a patient has a diagnosis of an
abscess of bursa of the right shoulder, the
appropriate code is M71.011 (abscess of bursa,
right shoulder).
In ICD-9-CM, coders would report this condition
with code 727.89 (disorder of
synovium/tendon/bursa), which lacks site and
laterality specificity.
ICD-10- Prepare Now
For 34 years, a closed, midcervical fracture of the
femur has been coded as 820.02, using ICD-9,no
other information needed
ICD-10-CM requires additional detail—Is it the right
femur or the left femur? Is this an initial encounter
or a subsequent encounter? Is the fracture healing
nicely or delayed? ICD-10 has four codes and your
documentation must note which femur, what type
of encounter, and whether a complication exists.
Take Away
Document Who
Document What
Document Why
Document How
Document When
Contact Information

CDS – Michele E. Huguley RN
 (9)646-9235
 mhuguley@lumc.edu
 CDS – Gail Klotz RN BSN
 (9)250-4108
 gklotz@lumc.edu
 Manager - Nancy Ignatowicz RN, BS, MBA, CCDS
 (9)646-9057
 nignatowicz@lumc.edu
Contact Information

Lead Coders – Anjie Marth
 x64559
 amarth@lumc.edu
 Lead Coders –Pattie Hise
 x68542
 phise@lumc.edu
 Manager – Shelley L. Oglesby, M.Ed, RHIT,CCS-P
 x62132
 soglesb@lumc.edu