metric(s)

Unknown

When an answered query gives specificity to the PDx but does not change the DRG or SOI/ROM, how can we reflect that effort for instance on a spreadsheet?

For instance, 4280-CHF unspecified with existing pneumonia as a secondary will give DRG 291. The answered query for Heart Failure specificity may be 42821, Systolic Heart Failure, acute. With the same secondary, the DRG will remain 291.

dvitalone1

We mark it as "documentation improvement without DRG change" It is still a "win" for CDI!!!

kshumpert

If the diagnosis does not increase SOI/ ROM or change the DRG, I log it on my spreadsheet under MCC or CC heading. When I go over the report, I report on those 2 columns as well. Although not initially important for the above stated reasons, it will help with a RAC audit. One area of RAC target are charts with one CC or MCC. The more the merrier:) I just address what I see missing no matter what is there, striving for a complete record.

Thanks,
Kathy
Kathy Shumpert, RN, CCDS

Clinical Documentation Improvement Specialist
Howard Regional Health System
Office 765-864-8754
Cell phone 765-432-3961
Fax 765-453-8152

When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela