MO230 Chapter 002

Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Chapter 2
The Health Record as the Foundation
of Coding

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.

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
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
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

 Therapeutic treatment
• Medications
• Therapies
• Surgery

 Diagnostic procedures
• To determine underlying causes

 Extended length of hospital stay
• Conditions that require:
 Investigation
 Monitoring
 Watchful waiting

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

records
 Reporting of coexisting chronic conditions
• Conditions being evaluated or monitored

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

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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