Approved Abbreviation Lists

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
Does everyone have an approved abbreviation list for MD/CDI/coders and your institution? When I started this job a few months ago, i was told we did have one but have come to find out we do not. Coders are often coding abbreviations but it is inconsistent and not backed up by policy.
The coding maneger and myself find this concerning and want to take it to our surperiors but want to make sure we have good reason to do so.
My reasons to have one is for consistency/accuracy of coding as well as the issue that I am assuming that not having an approved list could make us vulnerable to RAC (and other) reviews. If a dx is coded based on a abbreviation when we do not have an approved list, couldnt they say that there is no way to be 100% sure that the dx was appropriate?
I'm new to this and just trying to work this out.
Any advice would be appreciated. If you have a copy of your approved list, that would be great too.

Thanks,
Katy

Comments

  • ssalinasssalinas
    edited May 2016
    This is our official list. Probably needs to be updated but it will provide a starting point. Also need to make sure the medical staff is aware of it and uses only approved abbreviations. Common sense has to be used when finding abbreviations in the chart to be sure the physician means what the 'official list' says.
  • robert.hodges2robert.hodges2
    edited May 2016
    We also have a facility approved list. The challenge is getting the providers to use it properly and not make up their own abbreviations. I guess you can't have everything.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    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

    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
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