RE: [MARKETING] [EXTERNAL] Documentation with no clinical support
The query forms sent to confirm documentation w/o clinical support are useful - and, I endorse Roberts' stance that the AHIMA/ACDIS Best Practice states one should query in such situations.
However, how many of us have a viable escalation process for these situations?
It would be best to have physician-to-physician communication if/when the physician resists input from the CDS. (What do you do if the MD either ignores your query - what does the coder do - remove the code)?
Theoretically, this is a fine process, but the devil is in the details if the MD either refuses to answers or refuses to amend charting when a condition may not be warranted. We need to think about the downstream implications for Coding and Billing.
No solutions on my part, just these nagging worries.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
evanspx@sutterhealth.org
However, how many of us have a viable escalation process for these situations?
It would be best to have physician-to-physician communication if/when the physician resists input from the CDS. (What do you do if the MD either ignores your query - what does the coder do - remove the code)?
Theoretically, this is a fine process, but the devil is in the details if the MD either refuses to answers or refuses to amend charting when a condition may not be warranted. We need to think about the downstream implications for Coding and Billing.
No solutions on my part, just these nagging worries.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
evanspx@sutterhealth.org