One of the most important aspects of documenting your evaluation and treatment of inpatients in the medical record is providing the verbiage that meets your goals for describing your patient. When you provide the right words, the coders assign the right codes.
I have received several questions related to my “Standards of the month” column about history and physical (H&P) reports.
I thought it would be a good idea to clarify two specific issues these inquiries raised: 1) the requirements for H&P examinations for moderate sedation, and 2) allowing anesthesiologists to complete the update to the H&P report prior to surgery.
In severity and risk adjustment, defining acute kidney disease, specifically acute renal failure (ARF) and its synonym, acute kidney injury (AKI), are confounding issues for physicians, coders, and quality specialists. When do patients with elevated creatinine levels or oliguria have ARF or AKI, a major complication and comorbidityunder MS-DRGs? How do ARF, AKI, and other terms, such as acute renal insufficiency or azotemia, factor in risk adjustment?
If you’ve been outsourcing your transcription but think there might be a better way to meet your needs in-house, you may want to take another look at some other options. You may have more than you realize.
It may be too early to start intensive ICD-10-CM training for your coding team, but now is a good time for your coders to at least become familiar with features of the new system.
The transition to ICD-10 is not in any way the kind of transition we made from ICD-8 to ICD-9, nor is it a simple matter of training coders and implementing a revised encoding system. This will probably be one of the biggest transitions hospitals and HIM directors and coders have seen in many years.
