ICD 10 Coding Alert

Expect denials when documentation doesn’t support your code selection.

You may be able to choose diagnosis codes with the precision of a sharpshooter, but if the clinical record doesn’t support the codes you report, you run the risk of down coding, focused medical review, and even fraud investigations. The documentation on which you base your coding is about to get even more scrutiny as the Oct. 1, 2014 ICD-10 transition date approaches. Make sure your clinicians’ documentation techniques will pass muster with these expert tips.

Now’s the time to assess clinicians’ documentation skills, says Arlene Maxim, RN founder of A.D. Maxim Consulting, A.D. Maxim Seminars, and The National Coding Center, in Troy, Mich. Under ICD-10, clinicians will need to beef up their documentation, she says.

“Documentation will make or break this process,” Maxim tells Eli. ICD-10 will require a higher degree of specificity. Assessing documentation practices now allows your agency to begin improvement efforts before the added pressure of the ICD-10 deadline arrives.

Clinical documentation is the foundation of every health record, said Dorothy D. Steed, CPC-H, CHCC, CPUM, CPUR, CPHM, ACS-OP, CCS-P, RCC, CPMA, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CPAR, AHIMA Approved ICD-10 Trainer, an independent healthcare consultant and educator in Atlanta, Ga. Clinicians may collect documentation only once, but others will use it many times so it’s important to make every effort to prevent it from being misunderstood.

Clinicians need to think about how often others will use and access their documentation in the future, Steed said during the recent Eli-sponsored audioconference “Clinical Documentation Improvement.” This critical information is needed for patient care.

Documentation and coding go hand-in-hand, Steed said. The “coder needs high quality documentation to determine coding quality and accuracy.”

Steed outlined seven criteria for quality clinical documentation. Consider how your clinicians’ documentation stacks up in each area and provide help in making the changes needed to better support coding choice.

1. Legibility: Documentation should be readable and easily deciphered. A lot of handwritten documentation isn’t legible or decipherable, Steed cautioned. Rushed or careless documentation may cause other problems.

Legibility includes being able to read the name and title of the clinician completing the documentation, Maxim says.

This is an especially important aspect of good documentation, Steed said. Complete and legible entries provide protection for providers. But illegible entries in a medical record may cause:

• Misunderstanding of a patient’s condition.
• Jeopardized reimbursement.
• Denied payment.
• Loss of legal appeals.
• Serious patient injury.

2. Reliability: Is the documentation trustworthy? Based on the diagnoses, is the documentation reliable? Does it support the rationale for the diagnoses and for medical necessity?

The reliability is not just related to the assessment (OASIS), but with every single visit note. Most denials and down coding occur when visit notes don’t support the codes you report based on the original assessment, Maxim cautions.

3. Precision: Clinical documentation must be accurate, exact, and strictly defined. Increased detail generally means greater accuracy in documentation, Steed said.

The degree of specificity in documentation that will be necessary with ICD-10 will challenge even the most experienced home care clinician, Maxim says.

4. Completeness: Good documentation fully addresses all concerns in the record, and includes appropriate validation. Be absolutely sure every SOC assessment includes the beneficiary’s prior level of function.

When records go under review by any contractor, the prior level of function will assist in supporting the need for home health care services, Maxim says.

5. Consistency: Documentation shouldn’t be contradictory. Are there conflicting statements in the record? Are there conflicting opinions between providers that have not been clarified? Make sure any inconsistencies are addressed.

This is where the coordination of services comes into play, Maxim says. Many times a contradiction occurs when there is a lack of communication between the disciplines. “Get everyone on the same page.”

6. Clarity: Documentation should be unambiguous. Vague documentation that does not totally describe a patient’s condition won’t support the services your agency provides.

7. Timeliness: Documentation must be up-to-date to help ensure optimal patient treatment.

Home health example: This includes the need for clinicians to document in the home, Maxim says. Clinicians should never be tempted to put off documentation until a more convenient time. Every hour away from the visit, a large percent of information is lost. “Our memory for specific information fades quickly. Agencies should begin enforcing requirements of in-home documentation.”

You’ll want to watch for under-documented OASIS areas such as Vision impairment (M1200). The clinical documentation must be consistent with any problems identified in this item. If your patient’s vision scores as partially or severely impaired, you’ll need to show evidence of it in the medical record. Good documentation includes details such as “provided large print reading materials,” “made suggestions about improving the lighting for safety” or comments indicating that the clinician considered the patient’s vision problems and their impact on medication management.

It is also important to include any diagnosis- or problem-related issue that causes vision impairment, Maxim says. Good documentation describes why the patient’s vision is impaired and just how such impairment will impact the plan of care.