Poor vs. Thorough Charting Examples
Hello, I don't post very often but I do appreciate all the of the feedback and questions that are asked on this website. It is very helpful! So thank you!
I am presenting to our hospitalist team this evening and wanted to present examples of good and poor charting to show them the different it can make. I have a few put together, but does anyone have more examples that show the difference good charting can make to SOI, ROM, etc.?
Thank you for any help you can give me!
Rebekah Foster RN CCDS
Kaweah Delta Medical Center
400 W. Mineral King
Visalia CA 93291
559-6240-5085
rfoster@kdhcd.org
I am presenting to our hospitalist team this evening and wanted to present examples of good and poor charting to show them the different it can make. I have a few put together, but does anyone have more examples that show the difference good charting can make to SOI, ROM, etc.?
Thank you for any help you can give me!
Rebekah Foster RN CCDS
Kaweah Delta Medical Center
400 W. Mineral King
Visalia CA 93291
559-6240-5085
rfoster@kdhcd.org
Comments
Anoxic encephalopathy = CC (similar to the permanent state that occurs for
pt's that are "down" > 6 minutes before CPR initiated)
Metabolic encephalopathy due to hypoxemia = MCC (usually reversible - see
it often in those pt's that present w/ acute resp failure - resolves when
the underlying oxygenation issues are corrected)
MD's often use these terms interchangeably, despite the fact that they
represent different scenarios and have different impact in the coding
world.
Good luck with your meeting tonight!!
Cindy Pritchett, RN, BSN, CCDS
MedPartners CDI Consultant
2 SEPSIS Examples of how documentation can change the DRG
Example #1 Example #2
038.0 - Strep septicemia 038.0 - Strep Septicemia
482.30 - Strep pneumonia 995.92 - Severe sepsis
402.91 - HCVD w CHF 785.52 - Septic shock
428.0 - CHF, unspecified 482.30 - Strep pneumonia
428.31 - Ac Diastolic CHF 402.91- HCVD w CHF
428.0 - CHF, unspecified
96.71 - Vent.96 hrs
96.04- Insert, ET
3- Major, Severity of Illness 4- Extreme, SOI
3- Major, Risk of Mortality 4- Extreme, ROM
DRG – 871 DRG – 870
RENAL FAILURE Documentation examples which impact SOI/ROM & reimbursement
Example #1 Example#2
586 - RF, unspecified 584.6 - ARF, w tubular necrosis
250.00 - Diab, unspecified 250.42 - DM, II, uncntrld w ren manifestations
428.0 - CHF, unspecified 428.33 - Diastolic HF, acute on chronic
585.5 - CKD, stage V
2 - Moderate, Severity of Illness 3- Major, SOI
2 - Moderate, Risk of Mortality 2- Moderate, ROM
DRG – 684 DRG – 682
DIABETES Documentation Examples which impact SOI/ROM:
Example #1 Example#2
250.00 - DM, unspecified 250.42 - DM, Type II, uncntrlld, w CKD
585.9 - CKD, unspecified 585.5 - CKD, Stage 5
403.90 - Htn+CKD, unspecified 404.91 – HCVD & CKD c CHF
428.0 - CHF, unspecified 428.31 - Diastolic, HF, acute
1- Minor, Severity of Illness 2- Moderate, SOI
2- Mod., Risk of Mortality 3- Major, ROM
DRG – 639 DRG – 698
Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com
Rebekah Foster RN CCDS
Kaweah Delta Medical Center
400 W. Mineral King
Visalia, CA 93291
559-624-5085
rfoster@kdhcd.org