# Compliance question, symbols



## Love Coding! (Apr 15, 2011)

Hello,

I am looking for an answer to this question.  In regards to inpatient services, does anyone know if Medicare (Noridian, Palmetto, Trailblazer) has a rule when it comes to using symbols (+ -, ↑, ↓ ) to describe the patients diagnosis with out writing out the diagnosis, examples below... are these acceptable to use?  Would anyone know where I can find answer to this?  Thank you!

Hyperpotassemia -  ↑ K 
Hypertension - ↑ BP
Hypotension - ↓ BP


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## btadlock1 (Apr 15, 2011)

021402 said:


> Hello,
> 
> I am looking for an answer to this question.  In regards to inpatient services, does anyone know if Medicare (Noridian, Palmetto, Trailblazer) has a rule when it comes to using symbols (+ -, ↑, ↓ ) to describe the patients diagnosis with out writing out the diagnosis, examples below... are these acceptable to use?  Would anyone know where I can find answer to this?  Thank you!
> 
> ...



I would say yes - they're easy to understand...this is from Cigna Governmental Services:
http://www.cignagovernmentservices.com/partb/claims/cert/Articles/cope9014.html
"CHECK YOUR RECORDS FOR THE FOLLOWING … 
Records are legible; all abbreviations and symbols will be easily recognized by reasonable clinicians..."


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## RebeccaWoodward* (Apr 16, 2011)

021402 said:


> Hello,
> 
> I am looking for an answer to this question.  In regards to inpatient services, does anyone know if Medicare (Noridian, Palmetto, Trailblazer) has a rule when it comes to using symbols (+ -, ↑, ↓ ) to describe the patients diagnosis with out writing out the diagnosis, examples below... are these acceptable to use?  Would anyone know where I can find answer to this?  Thank you!
> 
> ...



In the event that a carrier/auditor does not recognize your physicians symbols, you should incorporate these symbols into your company compliance plan and place these symbols in your compliance plan/manual.  When the carrier requests the medical record (for whatever reason) you will want to send them a copy of these symbols and how they translate into the physicians terminology.  When our provider creates a unique abbreviation/symbol, we place this information into the physicians file and have the provider sign off on this information.  Leaves little room for misinterpretation.


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