New Year's Resolution No. 1: Discard the sports-related mantra that "if you're not cheating, you're not trying hard enough."
Instead, keep in mind that just because you CAN get away with something doesn't mean you should. In 2011, let's try to get it right the first time, every time.
Here are some examples of some exercises to start off the New Year:
There is physician documentation of atelectasis seen on CXR. It is a two-day stay for a fractured hip repair with discharge to a nursing home. The CXR is done preoperatively. There is no treatment ordered and none rendered, with no follow-up CRX. Do you code the atelectasis, since it was documented twice by two physicians in the record?
A patient presents to the ER from a nursing home with a chronic Foley catheter draining cloudy urine, and the Foley is changed in the ER. The patient is admitted with a UTI, and the attending physician never mentions the Foley catheter in his documentation. Do you query the physician for linkage to a device-related infection?
A patient exhibits lysis of adhesions (from a prior abdominal surgery) during planned removal of an ovary. During the dissection, the physician notes a "tear in the uterine wall," which he sutures with three stitches of 3-0 Vicryl. Do you query the physician about an intraoperative laceration?
A patient has a one-day stay with an admitting diagnosis of chest pain and a final diagnosis of noncardiac chest pain. Within the chart, the physician entertains the possibility of GI and lists the cause of the chest pain as gastritis. Do you code gastritis as PDX?
A patient is admitted with acute renal failure, probably due to home over-medication of Lasix. The patient is treated for the renal failure and other conditions that arise during the stay, and at the end of the 10-day hospitalization, the physician who does the discharge summary only states "acute renal failure" as the PDX. The patient is discharged on a lower dose of Lasix than that which he had been on prior to admission. Do you ignore the "probably due to" that was recorded only on admission?
A patient suffers a laceration to the lower leg at home and does not present for medical care for 10 days, meaning the injury is now an 8-cm round wound with cellulitis that grows MRSA. What do you sequence as PDX? Do you use the cellulitis as PDX, or sequence it as a CC with an open wound of the leg?
A patient presents to the ER with confusion and falls and is found to have both a traumatic acute subdural hematoma and an acute urinary tract infection (the patient subsequently is admitted). Do you sequence the UTI as the PDX for the CC of subdural hematoma?
A patient is admitted in a hypotensive state. Various causes are considered throughout the stay. Consultations are held with cardiology, neurology, nutrition and internal medicine. Occupational therapy consult is obtained. Medications are adjusted according to the medication reconciliation form, and the patient is told to be cautious in standing from a sitting position. Final diagnosis is "hypotension, multifactorial." Do you query the attending physician to determine what he or she feels is the "most likely" cause, or do you assign "hypotension, NOS," which is the highest weighted MS-DRG assignment of the multiple "possible" causes noted throughout the chart?
A patient is admitted and treated for pneumonia. The physician records "protein malnutrition." The patient weighs 165 pounds and is ordered an 1,800-calorie ADA diet. The protein lab value was slightly low at 6.7, and there was a slight drop in albumin to 3.1, with no BMI documented and no nutritional consultation obtained. Do you code 260 (MCC) for Kwashiorkor? Or do you query the physician for the severity and relevance of the patient's malnutrition, which may result in a CC or a data quality-only code?
Do you favor efficiency in coding, revenue capture and a lower DNFB over the physician query process, which could add to your clinical data quality and give a truer picture of your patients and their conditions? Ultimately, it is the entity's choice of culture: either take what you can now (and give some back later if you have to) and get the bills out the door, or take your time, query the physicians, teach the documenters, educate the coders, implement a CDI program and code compliantly.
New Year's Resolution No. 2: Adopt this updated sports-related mantra instead: "The real winners never cheat, and cheaters never really win." Especially on the RAC racetrack.
About the Author
Janelle Wissler, RHIA, CCS, CMT, CCDS, has more than 26 years of HIM coding, compliance, and governmental audit experience.
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