While providers and coders work together in the health-care field, there are notable differences between the clinical and the coding worlds. Providers are not always aware of every coding guideline, and this can sometimes result in documentation that is not as specific as needed for coding purposes. This lack of specificity can cause confusion at times. An example of this is documenting current and historical conditions in the medical record. It is a longstanding practice for providers to use…
Category Archives: "Clinical Documentation Excellence"
Documenting Major Depressive Disorder
By Denise Wills, CPC-A
When documenting depression, accuracy is important in determining the most specific code. If incomplete documentation is received, it will result in an unspecified code selection, which does not map to an HCC. For example, ICD-10 code F32.9 (MDD, single episode, unspecified) does not map to an HCC, whereas F32.0 (MDD, single episode, mild) does.
The ICD-10 classification of Mental and Behavioral Disorders, developed in part by the American Psychiatric Association, classifies depression by code. Documentation of Major…
Progress Notes: Provider Education and Support
By Richard Schamp, MD
CEO
Richard Schamp, MD, CEO
In our last edition, I mentioned the burgeoning new competency for physicians and other clinical providers – clinical documentation excellence. Let’s delve further into some specifics around the kinds of competence required in a risk-adjusted payment model. CMS has a process to verify that diagnosis codes reported that are relevant for payments in the HCC (Hierarchical Condition…
Clinical Documentation: A New Competency for Providers?
By Richard Schamp, MD
CEO
Richard Schamp, MD, CEO
Multiple risk adjustment models are active across the US healthcare landscape. If you are reading this, you probably already live in a risk-adjusted payment world. For example, the Centers for Medicare & Medicaid Services (CMS) uses a risk-adjusted model that pays PACE and Medicare Advantage plans based on a person’s demographics and age, with additional payments made…
Coding for Diabetes in ICD-10
By Lynn Diorio, CCS-P, CRC
Risk Adjustment Coder
Coding for diabetes can be a daunting process. Clear and concise documentation by the provider is key in helping to ensure that the condition is captured appropriately. There are five major categories that diabetes can fall into in ICD-10: Type 1 (E10); Type 2 (E11); Diabetes due to underlying condition (E08); Drug or chemical-induced (E09); and other specified (E13).
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Documenting and Coding Nephropathy and Chronic Kidney Disease
By Richard Schamp, MD
CEO, Capstone Performance Systems
Definitions
Nephropathy refers to any disease of the kidney. In common clinical parlance, the term is modified by an etiology referring to one of over a dozen types, such as analgesic nephropathy, gouty nephropathy or most commonly, diabetic nephropathy. Chronic Kidney Disease (CKD) is defined by GFR (Glomerular Filtration Rate) less than 60 ml/min per 1.73 m2 and/or kidney damage for three or more months. The presence of albuminuria is most commonly used to…
How Past Conditions Affect Current Documentation and Coding
By Jan Deyber, CRN-C, and Tiffany Brookshire, BSN, CRN-C
We often see inconsistency in medical records regarding diagnoses as current or historical. Documenting “history of” when referencing a patient’s past medical background is a longstanding practice. Providers may intend a “present perfect” tense – a condition that started in the past and continues in the present. However, in the world of diagnosis coding, “history of” indicates a past (or past perfect) tense; in other words, a condition that no longer…
Changing Documentation in the Medical Record
by Richard Schamp, MD, Chief Executive Officer
When documenting in the medical record, providers should take care to capture their thoughts and findings as completely as possible. Best practice is to document the patient encounter at the time, or shortly afterwards. Inevitably, situations require some changes in the medical record, of which four types are recognized. (more…)
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