The Documentation Equation: Tell Me a Story

The Documentation Equation: Tell Me a Story

An important part of inpatient medical coding training is not only learning how to apply codes, but also knowing when not to code diagnostic terms that are not supported in the documentation.

Case study: A 49 year-old patient is admitted as an inpatient for a right hemicolectomy with end-to-end anastomosis for a large cecal polyp which is documented as malignant. After the surgery, the physician documents in the progress notes for three consecutive days that the patient had a post-operative ileus that was monitored and treated with sips of clear liquids and eventually improved. The coder codes Postprocedural intestinal obstruction, K91.3, which is a CC for C18.0 Malignant neoplasm of the cecum. An auditor reviews the claim and decides the diagnosis of post-operative ileus was not clinically supported and that the monitoring and treatment of the ileus did not go above the standard treatment of care for a patient with a hemicolectomy and the CC is denied and the DRG is changed from 330 to 331.

The coding guidelines’ criteria for coding a secondary diagnosis are clinical evaluation, therapeutic treatment, diagnostic evaluation, extended length of stay and increased nursing care and monitoring. Many times these five criteria can be found throughout the chart in the nursing notes, in the radiology and ancillary reports, as well as physician documentation. The days of playing word search in an inpatient chart are over. Using “Control F” to locate an MCC or CC documented once in the chart is a poor coding practice. Adequate documentation to support a diagnosis is not just a word, it's a story. If a diagnosis is merely listed without supporting clinical indicators, it will fall under the scrutiny of auditors. Coders should look for the doctor's thought process in the documentation that support the diagnosis documented. Clinical indicators should be present in the medical record that explain the diagnosis. From a coder’s perspective, a clinical indicator is a sign, symptom, diagnostic test or treatment defines a diagnosis. The doctor should explain how he arrived at the diagnosis, list the differential diagnoses and document what was ruled out.  The physician should document the progression of the condition. The documentation of a diagnosis should give an indication of the severity, improvement, or worsening of the condition over time. Was the treatment intensified, were medications changed, and how did the clinical indicators change over the admission?  The physician should document how the diagnosis relates to other conditions that the patient has. Is the diagnosis a causal agent for another condition, is the diagnosis due to another condition, is it causing issues with other body systems? The doctor should document the treatment related to the condition. For example, if a patient has respiratory failure, the number of liters per minute of oxygen should be documented.
Let’s look at a case study: A patient arrives to the hospital and is admitted with severe pneumonia and acute hypoxic respiratory failure requiring 10 L of O2 to maintain 92% O2 sats. The patient is treated with antibiotics and nebulizers. On the first progress note the documentation states "the patient meets sepsis criteria with tachycardia and fever." The next progress note states "sepsis, resolved." The following progress notes don’t mention sepsis and sepsis is not mentioned on the discharge summary or the H&P, yet the clinical documentation specialist factored the sepsis into their DRG. 
Do you code it? Do you query? In this case, there is not enough documentation to code the sepsis. How was it treated? What was the patient's progress? None of this is documented. In this case I would not code it, although a query may be indicated. Depending on the rest of the documentation and the circumstances of admission either the pneumonia or the acute respiratory failure would be principle diagnoses in the absence of a query.

If a patient arrives at 80% O2 sat on room air with SOB and receives 4L – 6L of O2 throughout to maintain 96%L and the physician calls it “acute hypoxia” all throughout consistently, the coder should code the “acute hypoxia” and not query unless other documentation points to another diagnosis.

What if the opposite scenario occurs? If a patient arrives at 90% on room air with slight SOB and receives 4L of O2 throughout to maintain 96% and the physician calls it “acute respiratory failure” consistently throughout the chart. Should the coder what was documented? In cases like these, the coder would want to send the chart for a second level review. Some facilities have physician documentation champions who will review these types of cases.

It is not the coder’s job to question the judgement of the physician or decide whether or not the patient actually has the condition that is documented, it is the coder’s job to identify unclear, inconsistent, and inadequate documentation and to code the diagnoses that are adequately supported in the documentation.

Here are some examples of excellent documentation:

“Hypoxemic respiratory failure. Acute, POA, evidenced by SpO2 84% on RA (=PAO2 49) + tachypnea (RR 20) = symptomatic shortness of breath in the setting of CHF, continue to diurese, continue supp O2, continue HS CPAP, chest xray suggestive of dilated stomach, monitor PO intake”

“AKI on CKD. Acute, POA, evidenced by rise in serum Cr from baseline 1.1 (outside record reviewed characterizing patient’s baseline eGFR as 90 w/ Cr 1.1 and 24-hr urine collection) to 1.7 in setting of 1 month of NSAID use, ongoing diuretic use, FeNA 2.9%, suspect this is a combination of hypoperfusion in setting of CHF and NSAID use, in setting of CKD, d/w with nephrologist, s/p Lasix in ED, continue IV 2xd, hold aldactone while aggressively diuresing w/ Lasix, then reinitiate, monitor UOP and Cr, if UOP declines, then get bladder scan”

A great inpatient medical coding training course will teach the student to recognize diagnoses that can and can’t be coded by using real case studies. Remember: Great documentation is not a word; it is a diagnostic statement plus clinical evidence.



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