RE: [MARKETING] [EXTERNAL] Documentation with no clinical support
I completely agree Paul, I have seen this. Plus, what do you do with an 'unable to determine' response? We've had this happen several times for Clinical indicator queries or Rule in/out queries. It makes it very tough for coding and is something we have to be mindful of.
I really liked the blog from a few months ago that stated that we should not be 'armchair quarterbacks' validating dx.
http://blogs.hcpro.com/acdis/2013/08/qa-querying-for-clinical-validation-of-a-diagnosis/
We really should only be querying when there is no reasonable evidence of a condition. If you look at the examples in the ACDIS brief, they are obvious errors. Like documentation of hyponatremia when we obviously have hypernatremia. Or documentation of no surgical complications when we have a laceration documented.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
I really liked the blog from a few months ago that stated that we should not be 'armchair quarterbacks' validating dx.
http://blogs.hcpro.com/acdis/2013/08/qa-querying-for-clinical-validation-of-a-diagnosis/
We really should only be querying when there is no reasonable evidence of a condition. If you look at the examples in the ACDIS brief, they are obvious errors. Like documentation of hyponatremia when we obviously have hypernatremia. Or documentation of no surgical complications when we have a laceration documented.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404