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Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Chapter 2
The Health Record as ...
2Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Lesson 2.1: The Health Record
...
3Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
The Health Record
 One for ea...
4Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
The Health Record
 Describes ...
5Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
The Health Record
 Current fo...
6Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
The Health Record
 General Pr...
7Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
The Health Record
 General Pr...
8Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
The Health Record
 General Pr...
9Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Sections of the Health Record
...
10Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Sections of the Health Record...
11Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Sections of the Health Record...
12Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Sections of the Health Record...
13Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Sections of the Health Record...
14Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Sections of the Health Record...
15Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Sections of the Health Record...
16Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Sections of the Health Record...
17Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Sections of the Health Record...
18Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Sections of the Health Record...
19Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Sections of the Health Record...
20Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Sections of the Health Record...
21Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Sections of the Health Record...
22Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Sections of the Health Record...
23Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Lesson 2.2: Reporting Diagnos...
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UHDDS Reporting Standards for...
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UHDDS Reporting Standards for...
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 Principal procedure
 The p...
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 Other diagnoses
 Condition...
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 Other reportable diagnoses ...
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 Other reportable diagnoses ...
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 Other reportable diagnoses ...
31Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
 Other reportable diagnoses ...
32Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
 Other reportable diagnoses ...
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 Guidelines for reporting ad...
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 Guidelines for reporting ad...
35Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
 Guidelines for reporting ad...
36Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
 Guidelines for reporting ad...
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Coding from Documentation Fou...
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Coding from Documentation Fou...
39Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Coding from Documentation Fou...
40Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Coding from Documentation Fou...
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Coding from Documentation Fou...
42Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Coding from Documentation Fou...
43Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Coding from Documentation Fou...
44Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Coding from Documentation Fou...
45Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Coding from Documentation Fou...
46Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Coding from Documentation Fou...
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Coding from Documentation Fou...
48Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Coding from Documentation Fou...
49Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
QUESTIONS
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MO230 Chapter 002

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MO230 Chapter 002

  1. 1. Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Chapter 2 The Health Record as the Foundation of Coding
  2. 2. 2Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Lesson 2.1: The Health Record  Explain the purpose of the various forms or reports found in a health record.
  3. 3. 3Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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
  4. 4. 4Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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
  5. 5. 5Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. The Health Record  Current format of health records  Electronic  Paper (traditional)  Electronic and paper “hybrids”
  6. 6. 6Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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
  7. 7. 7Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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
  8. 8. 8Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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
  9. 9. 9Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sections of the Health Record  Administrative Data  Demographic  Personal  Consents
  10. 10. 10Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sections of the Health Record  Clinical Data  Emergency room documentation  Admission history and physical (H&P)  Physician orders  Progress notes by healthcare providers  Anesthesia forms  Operative notes
  11. 11. 11Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sections of the Health Record  Clinical Data  Recovery room notes  Consultations  Laboratory test results  Radiology test results  Miscellaneous ancillary reports  Discharge summary
  12. 12. 12Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sections of the Health Record  Clinical Data  Requirements for data mandated by: • Joint Commission • Medical Staff Bylaws • Federal Government Guides • UHDDS Discharge Data Set  DOB  NPI
  13. 13. 13Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sections of the Health Record  Emergency Record  Mini medical record • Chief complaint • Other medical services during visit • Working diagnosis • Discharge or transfer disposition
  14. 14. 14Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sections of the Health Record  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
  15. 15. 15Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sections of the Health Record  Physician Orders  Attending physician  Consultants  Written or verbal
  16. 16. 16Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sections of the Health Record  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
  17. 17. 17Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sections of the Health Record  Nursing notes  Integrated or separate  Include: • Admission note • Graphic charts • Medications/treatments • TPR sheets
  18. 18. 18Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sections of the Health Record  Anesthesia forms  Pre-anesthesia  Post-anesthesia  Anesthetic agent used  Amount  Administration  Duration  Blood loss  Fluids
  19. 19. 19Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sections of the Health Record  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
  20. 20. 20Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sections of the Health Record  Consultations  Requested by attending physician  May be used to assess surgical risk • Surgical clearance  Within progress note or separate form
  21. 21. 21Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sections of the Health Record  Laboratory, radiology, and pathology reports  Electronic or paper  CBC  UA  Metabolic levels
  22. 22. 22Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sections of the Health Record  Discharge summary  History of present illness  Past medical history  Findings  Lab data  Other treatments or procedures performed  Final diagnosis  Discharge information
  23. 23. 23Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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.
  24. 24. 24Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. UHDDS Reporting Standards for Diagnosis and Procedures  Information extraction  Principal diagnosis • Other, secondary diagnoses  Principal procedure
  25. 25. 25Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. UHDDS Reporting Standards for Diagnosis and Procedures  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
  26. 26. 26Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.  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 UHDDS Reporting Standards for Diagnosis and Procedures
  27. 27. 27Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.  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 UHDDS Reporting Standards for Diagnosis and Procedures
  28. 28. 28Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.  Other reportable diagnoses are defined as additional conditions that affect patient care because they require:  Clinical evaluation • Testing • Consultations • Observation of status UHDDS Reporting Standards for Diagnosis and Procedures
  29. 29. 29Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.  Other reportable diagnoses are defined as additional conditions that affect patient care because they require:  Therapeutic treatment • Medications • Therapies • Surgery UHDDS Reporting Standards for Diagnosis and Procedures
  30. 30. 30Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.  Other reportable diagnoses are defined as additional conditions that affect patient care because they require:  Diagnostic procedures • To determine underlying causes UHDDS Reporting Standards for Diagnosis and Procedures
  31. 31. 31Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.  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 UHDDS Reporting Standards for Diagnosis and Procedures
  32. 32. 32Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.  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 UHDDS Reporting Standards for Diagnosis and Procedures
  33. 33. 33Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.  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 UHDDS Reporting Standards for Diagnosis and Procedures
  34. 34. 34Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.  Guidelines for reporting additional diagnoses for inpatient, short-term, acute care hospital records  Reporting of coexisting chronic conditions • Conditions being evaluated or monitored UHDDS Reporting Standards for Diagnosis and Procedures
  35. 35. 35Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.  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 UHDDS Reporting Standards for Diagnosis and Procedures
  36. 36. 36Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.  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 UHDDS Reporting Standards for Diagnosis and Procedures
  37. 37. 37Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Coding from Documentation Found in the Health Record  Key elements:  Chief complaint  Admission diagnosis  Use physician documentation  Qualified physicians • Attending • Consulting • Interns • Residents
  38. 38. 38Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Coding from Documentation Found in the Health Record  Types of physicians  Surgeons  Anesthesiologists  Oncologists  Internists  Hospitalists  Intensivists  Family practitioners  Interventionalists
  39. 39. 39Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Coding from Documentation Found in the Health Record  Radiology or pathology reports  What to code • Confirmed conditions from attending  What not to code • Conditions not referenced
  40. 40. 40Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Coding from Documentation Found in the Health Record  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
  41. 41. 41Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Coding from Documentation Found in the Health Record  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
  42. 42. 42Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Coding from Documentation Found in the Health Record  How to Query  Verbal or written  Always document the query  No leading queries  Do not use the word “possible”
  43. 43. 43Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Coding from Documentation Found in the Health Record  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
  44. 44. 44Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Coding from Documentation Found in the Health Record  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
  45. 45. 45Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Coding from Documentation Found in the Health Record  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
  46. 46. 46Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Coding from Documentation Found in the Health Record  Who to query  Query the provider who supplied the documentation in question • Consultant • Anesthesiologist • Surgeon • Attending physician
  47. 47. 47Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Coding from Documentation Found in the Health Record  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
  48. 48. 48Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Coding from Documentation Found in the Health Record  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
  49. 49. 49Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. QUESTIONS

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