Response to Physician when they say they should be coding the chart

cmorellcmorell
in CDI Talk Archive
Lately, the new trend when complaining about the queries is:
"There should be drop down boxes with the choices so when we say a diagnosis all the choices are there. We could code the chart just like in the office. Then we wouldn't need to be bothered with all of the queries".

My first thought are:
1. Outpatient coding and inpatient coding are very different.
2. Coding clinics and rules.
3. With the level of specificity it would take them 3 hours to do each progress note.
4. Have you seen the volume of codes in the ICD-9-CM for Hospitals-volumes 1, 2 & 3? It is going to get MUCH worse in 2014 with ICD-10.

Any other thoughts? Thanks!
Charrington "Charlie" Morell, RN, CCDS
Lead CDI Specialist
Regional Medical Center Bayonet Point

Comments

  • Unknown
    Yes, our CDI hear several comments similar to this all the time. We explain to the physician what we are there to do... no only capture the most appropriate severity of illness and risk of mortality but also the most accurate and concise documentation of the diagnosis the physician is treating. Or the reason the patient was hospitalized. All auditing firms are now trying to "deny" diagnoses that are addressed with a check in a box on a progress note. We have to defend many of these. Having the physician clicking or checking a drop down box is not the key to accurate and concise documentation. In my opinion, the physician should know why his documentation is so important.

    Juanita "Nita" B. Seel RN, CCDS, CDIP
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