MO230 Chapter 002

Chapter 2The Health Record as the Foundation

of Coding

Lesson 2.1: The Health Record

Explain the purpose of the various forms or reports found in a health record.

The Health Record

One for each patient Documents health history Timely Documentation in record should:

Identify patient Support diagnosis or reason for encounter Justify treatment Document results

The Health Record

Describes the patient’s health history Serves as a method for clinicians to

communicate Serves as a legal document of care and

services provided Serves as a source of data Serves as a resource for healthcare

practitioner education

The Health Record

Current format of health records Electronic Paper (traditional) Electronic and paper “hybrids”

The Health Record

General Principles of Medical Record Documentation Medical records should be complete and legible The documentation of each patient encounter

should include:• Reason for encounter and relevant history• Physical examination findings and prior diagnostic test

results• Assessment, clinical impression, and diagnosis• Plan for care• Date and legible identity of the observer

The Health Record

General Principles of Medical Record Documentation The rationale for ordering diagnostic and ancillary

services • If not documented, they should be easily inferred

Past and present diagnoses should be accessible for treating and/or consulting physician

Appropriate health risk factors should be identified Patient’s progress, response to changes in

treatment, and revision of diagnosis should be documented

The Health Record

General Principles of Medical Record Documentation International Classification of Diseases, 10th

Revision, Clinical Modification (ICD-10-CM & ICD-10-PCS) codes should be supported by documentation

Sections of the Health Record

Administrative Data Demographic Personal Consents

Clinical Data Emergency room documentation Admission history and physical (H&P) Physician orders Progress notes by healthcare providers Anesthesia forms Operative notes

Clinical Data Recovery room notes Consultations Laboratory test results Radiology test results Miscellaneous ancillary reports Discharge summary

Clinical Data Requirements for data mandated by:

• Joint Commission• Medical Staff Bylaws• Federal Government Guides• UHDDS Discharge Data Set

DOB NPI

Emergency Record Mini medical record

• Chief complaint• Other medical services during visit• Working diagnosis• Discharge or transfer disposition

Admission History and Physical (H&P) Chief complaint History of present illness Past medical history Family medical history Social history Review of systems Physical exam Impressions and plans

Physician Orders Attending physician Consultants Written or verbal

Progress notes: Usually in SOAP format Subjective: Chief complaint Objective: History, physical exam, and diagnostic

tests Assessment: Conclusion of subjective and

objective Plan: Steps to solve the patient’s problem

Nursing notes Integrated or separate Include:

• Admission note• Graphic charts• Medications/treatments• TPR sheets

Anesthesia forms Pre-anesthesia Post-anesthesia Anesthetic agent used Amount Administration Duration Blood loss Fluids

Operative Report Pre-op diagnosis Post-op diagnosis Dates Surgeons Findings Procedures performed Condition of patient at completion of procedure Dictated or written within 24 hours

Consultations Requested by attending physician May be used to assess surgical risk

• Surgical clearance Within progress note or separate form

Laboratory, radiology, and pathology reports Electronic or paper CBC UA Metabolic levels

Discharge summary History of present illness Past medical history Findings Lab data Other treatments or procedures performed Final diagnosis Discharge information

Lesson 2.2: Reporting Diagnoses and Procedures

Define “principal diagnosis.” Define “principal procedure.” Identify reasons for assigning codes for other

diagnoses. List the basic guidelines for reporting

diagnoses and procedures. Identify which types of documentation are

acceptable to use when assigning codes. Explain the query process.

UHDDS Reporting Standards for Diagnosis and Procedures

Information extraction Principal diagnosis

• Other, secondary diagnoses Principal procedure

Principal diagnosis The condition established after study to be chiefly

responsible for occasioning the admission of the patient to the hospital for care

Key to appropriate MS-DRG reimbursement

Principal procedure The procedure that is performed for definitive

treatment rather than for diagnostic or exploratory purposes, or a procedure that is necessary to take care of a complication

If two procedures meet the definition of principal, then the one most closely related to the principal diagnosis is designated as the principal procedure

Other diagnoses Conditions that coexist at the time of admission Conditions that develop after admission Conditions that affect the treatment Conditions that affect the length of stay

Other reportable diagnoses are defined as additional conditions that affect patient care because they require: Clinical evaluation

• Testing • Consultations• Observation of status

Other reportable diagnoses are defined as additional conditions that affect patient care because they require: Therapeutic treatment

• Medications• Therapies• Surgery

Other reportable diagnoses are defined as additional conditions that affect patient care because they require: Diagnostic procedures

• To determine underlying causes

Other reportable diagnoses are defined as additional conditions that affect patient care because they require: Extended length of hospital stay

• Conditions that require: Investigation Monitoring Watchful waiting

Other reportable diagnoses are defined as additional conditions that affect patient care because they require either: Increased nursing care and/or other monitoring

• May not need physician treatment• Conditions may need monitoring

Guidelines for reporting additional diagnoses for inpatient, short-term, acute care hospital records Previous conditions

• Sometimes part of discharge summary or H&P• May not be applicable to current stay• May be coded by hospital policy• V codes may be appropriate

Guidelines for reporting additional diagnoses for inpatient, short-term, acute care hospital records Reporting of coexisting chronic conditions

• Conditions being evaluated or monitored

Guidelines for reporting additional diagnoses for inpatient, short-term, acute care hospital records Integral vs. nonintegral conditions

• Conditions that are integral to the disease process are not assigned codes

• Is the condition a sign or symptom? Do not code

• Not associated with a disease process? DO CODE

Guidelines for reporting additional diagnoses for inpatient, short-term, acute care hospital records Abnormal findings

• Do not code unless clinically significant• Look for normal range indications• Look for further testing• In doubt? Query the physician

Coding from Documentation Found in the Health Record

Key elements: Chief complaint Admission diagnosis Use physician documentation Qualified physicians

• Attending• Consulting• Interns• Residents

Types of physicians Surgeons Anesthesiologists Oncologists Internists Hospitalists Intensivists Family practitioners Interventionalists

Radiology or pathology reports What to code

• Confirmed conditions from attending What not to code

• Conditions not referenced

The use of queries in the coding process The goal of queries

• Improve physician documentation• Improve coding professionals’ understanding of the

clinical situation• Not solely to improve the reimbursement• Ensure data integrity

When to Query Documentation describes or is associated with

clinical indicators without a definitive relationship to an underlying diagnosis.

Documentation includes clinical indicators, diagnostic evaluation, and or/treatment not related to a specific condition or procedure.

Documentation provides a diagnosis without underlying clinical validation.

Documentation is unclear for present on admission

How to Query Verbal or written Always document the query No leading queries Do not use the word “possible”

Query Format Open-ended Multiple choice

• Can provide a new diagnosis as an option Yes/No

• Determine present on admission (POA)• Further specify a diagnosis that is already documented• Establish a cause/effect relationship between

documented conditions• Resolve conflicting documentation from multiple

providers

Query Retention Policy Each facility should have a retention policy Practitioner response should be:

• Kept in the health record as an addendum• Written in a timely manner• Current date and time• Reason for additional documentation

Leading Query Not supported by clinical indicators found in the

record or directs provider to document a particular diagnosis or procedure

Query should only present clinical facts and allow provider to make a clinical determination

Who to query Query the provider who supplied the

documentation in question• Consultant• Anesthesiologist• Surgeon• Attending physician

Elements of a query form Date of query Patient name Medical record number Account number Admission date/date of service Question needing clarification with clinical indicators Identification of coder Contact information of the coder Area for provider response Place for provider signature and date of response Instruction, correction, or addendum

Ways to transmit queries to provider Fax Electronic via secure email or IT messaging Queries become part of the official health record Do not use sticky notes, scratch paper, or

anything that can be removed or discarded

QUESTIONS

MO230 Chapter 002

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