Overdocumenting

dogdog
in CDI Talk Archive
Does anyone have any good strategies for addressing what I call overdocumentation? For instance, I had a doctor who was calling every patient who came out of surgery on a vent (like a CABG) vent-dependent respiratory failure if he saw them on a vent. I knew he was wrong, but I couldn't convince him. I had to do a lot of research showing him journal articles with physician standards for postoperative respiratory failure before he would stop writing it. Also, and I know there was just a discussion here of ARF standards, some docs write ARF when there's no good evidence of it. Just a few examples.

Our coders will normally code what they read in the chart, so I get knocked down for my DRG not matching theirs when we reconcile. There is no mechanism in the software's query process for removing documentation or lowering a DRG, and I also don't know if as a nurse I have the right to tell a physician what he/she CAN'T put in the chart.

Sorry to be so long-winded. It's been bothering me for a while. Thx.

Comments

  • robert.hodges2robert.hodges2
    edited May 2016
    Personally I'm glad when I get detail, but I see your point about inappropriate documentation. You're doing what I would do. Educate the provider on what is appropriate and not appropriate according to the professional literature. I'm having debates and discussions with my providers on "renal insufficiency" vs. failure. It's been an interesting dialogue and I think we may even have some agreed upon ground soon.

    Good luck!

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
     
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    "To climb a steep hill requires a slow pace at first."  -William Shakespeare
     

  • kari.eskenskari.eskens
    edited May 2016
    If it helps your cause when discussing this with your medical staff, the ICD-9 guidance for use of the vent-dependent code (V46.11) specifies the following:



    [cid:image001.png@01CAAFEB.A56E11F0]



    If the patient is in-house and actively being treated and placed on a vent, they would not met this definition.



    Kari L. Eskens, RHIA

    BryanLGH Medical Center

    Coding & Clinical Documentation Manager



  • dallend@einstein.edudallend@einstein.edu
    edited May 2016
    We just had a similar discussion this morning with our compliance analyst and coding manager. Our problem is patients intubated for airway protection with diagnosis such as CVA or seizure. Our physicians document VDRF but the patient is not in resp failure. For these specific cases our coders have been instructed as of today to use the V code. The chart must state that the patient was intubated for airway protection and VDRF. Our compliance analyst has just completed the procedure. She also wrote coding clinic.
    Coding guidelines state that diagnosis must be coded if they meet sec diag guidelines which does not always correlate with clinical information.
    We no longer document our DRG agrees or disagrees. We stopped about 4 years ago. It was not fair that CDS was getting dinged for DRGs not matching when it was due to a coding guideline or a disagreement re: prin diag when 2 conditions present on adm for example.We are not coders and are not expected to know all of the coding rules. We focused more on queries and their impact, in addition to our SOI/ROM numbers. Management also looks at CMI.


  • dallend@einstein.edudallend@einstein.edu
    edited May 2016
    RE: telling a physician what they can or cannot put in a chart.
    We can only educate them. We have ARF documented on charts where the pt is definitely not in renal failure. The procedure at our facility and how we were trained is "right or wrong they have documented a definitive diagnosis" . My goal at my facility is to have those cases reported to our Chairs of surgery and medicine and have it handled MD to MD - right now it's just being ignored. We do not have a physician advocate. The coders will code these diagnosis because they may meet coding standards but not clinical standards - then the auditor comes in - they take the code away - you fight - you lose. You lose money.
    It's a long haul and every once in a while there is a ray of sunshine.


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