Coding for sepsis is often easier said than done. Obstacles range from difficulty distinguishing between documentation for sepsis and related conditions to trouble with physician queries.
Editor's note: The commentary in this article was originally presented in the HCPro, Inc., February 7 audio conference, "The Pediatric Medical Record: Opportunities for Documentation Improvement." Learn more about the audio conference at http://tinyurl.com/bbh9yl5.
At the Association of Clinical Documentation Improvement Specialists (ACDIS), questions on physician queries are never few and far between. Although AHIMA has published a couple briefs on the topic over the last decade, questions have still remained about how to implement a compliant and effective query process.
Editor's note: Medical Records Briefing (MRB) catches up this month with Monica Pappas, RHIA, president of MPA Consulting in Long Beach, Calif., and an MRB advisory board member, to discuss physician queries.
Everyone knows that CCs and MCCs are under scrutiny these days. However, that doesn't mean hospitals should err on the side of caution when reporting these conditions. William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Fla., provides several tips that coders can employ to look for clinical evidence in the record before querying for these targeted conditions.
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.
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.
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.
