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Improving documentation

November 2011
physician documenting billing on computer

Published in the November 2011 issue of Today’s Hospitalist

I would like to respond to your article, “Beware of leading queries“. I am a certified clinical documentation specialist, and I supervise the documentation integrity program at a leading teaching hospital in South Carolina. Our program has been in existence for seven years.

Most documentation improvement programs do not cross the line into physician coercion or fraud. Instead, these programs analyze physician documentation, align diagnoses with the treatment rendered and ensure that documentation appropriately captures the full range of services.

My staff are registered nurses “not coders “who review records from the clinical perspective to make sure documented diagnoses accurately reflect illness severity. When we send questions to physicians, we are trying to link medical diagnoses with the appropriate “coding world” language.

Documentation improvement programs are not designed to tell physicians how to practice. But many times, physician documentation lacks the clarity to accurately capture the true severity of illness and mortality risk.

The diagnosis of “urosepsis” is one example. For coders, “urosepsis” means that the only code they can assign has to do with a UTI. However, when documentation indicates “sepsis related to a urinary tract infection” (when the patient, of course, meets criteria for sepsis), coders can capture the true intensity of resources and services needed. Those could include IV antibiotics, frequent vital signs and increased nursing care.

With changes in health care and reimbursement, documentation must be clinically sound and appropriately capture severity of illness and mortality risk. But documentation improvement programs should be quality-driven, not financially-driven.

Information in the medical record is now used for many other areas besides billing: benchmarking, assessing the quality of patient care and of individual care plans, research, and hospitals’ HealthGrades ratings. Right now, documentation improvement programs are the only means by which hospitals can track all these key factors and ensure that publicly reported quality data are accurate.

The most successful documentation improvement programs abide by the standards and guidance of the American Health Information Management Association and the code of ethics of the Association of Clinical Documentation Improvement Specialists. We are a professional group and have worked hard to established standards to guide our programs.

Juanita B. Seel, RN, CCDS
Easley, S.C.

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