When HIM professionals at Driscoll Children's Hospital in Corpus Christi, Texas, looked into its success rate for physician response to coding queries, it knew it needed to do a better job.
Ensuring detailed documentation isn't important only with respect to documenting medical necessity. Case managers should also ensure physicians are including enough information in patient records to help them accurately estimate LOS, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS, CCDS, an independent health information management consultant in Madison, Wis.
There's a popular saying that states, "Too much of a good thing can be bad for you." I believe that's never been truer than now when it comes to EMR documentation.
On October 1, 2013, the ICD-10-CM and ICD-10-PCSclassification systems will take effect, and should result in better data capture nationwide. The change means healthcare organizations urgently need to educate providers on the importance of improved patient care documentation.
Editor's note: There are a number of ways to get information into the hands of your facility's physicians. The following list offers several suggestions on how to train and engage your medical staff. This article was adapted from the October issue of CDI Journal, a quarterly publication for members of the Association of Clinical Documentation Improvement Specialists (ACDIS). Additional information is available at www.acdis.org.
