RE: [EXTERNAL] RE:Documentation with no clinical support
Yes, we query for clinically unsubstantiated diagnoses. Our query is
similar to the one below. We've found that these queries often require
face to face follow up with the physicians; they confirm the diagnosis
but do not include their clinical indications. After discussion, if
there truly is no clinical evidence, they usually rule it out. It's a
difficult conversation, but our experience has been that the physicians
value our commitment to accuracy. Although, I've heard "that must be a
typo or a transcription error" many times, the discussions have also
resulting in learning opportunities for me and for the physician. At
the end of the day, we all know that our CD program is much more than
going after increased reimbursement.
Jillian Lightfoot RN
Clinical Documentation Team
Marshall Medical Center
Placerville, CA 95667
(530) 626-2770 Ext. 6203
lightfeet4@aol.com
similar to the one below. We've found that these queries often require
face to face follow up with the physicians; they confirm the diagnosis
but do not include their clinical indications. After discussion, if
there truly is no clinical evidence, they usually rule it out. It's a
difficult conversation, but our experience has been that the physicians
value our commitment to accuracy. Although, I've heard "that must be a
typo or a transcription error" many times, the discussions have also
resulting in learning opportunities for me and for the physician. At
the end of the day, we all know that our CD program is much more than
going after increased reimbursement.
Jillian Lightfoot RN
Clinical Documentation Team
Marshall Medical Center
Placerville, CA 95667
(530) 626-2770 Ext. 6203
lightfeet4@aol.com