Poor vs. Thorough Charting Examples

CLINDOCSPECLISTCLINDOCSPECLIST
in CDI Talk Archive
Hello, I don't post very often but I do appreciate all the of the feedback and questions that are asked on this website. It is very helpful! So thank you!

I am presenting to our hospitalist team this evening and wanted to present examples of good and poor charting to show them the different it can make. I have a few put together, but does anyone have more examples that show the difference good charting can make to SOI, ROM, etc.?

Thank you for any help you can give me!

Rebekah Foster RN CCDS
Kaweah Delta Medical Center
400 W. Mineral King
Visalia CA 93291
559-6240-5085
rfoster@kdhcd.org

Comments

  • cindy.pritchett04cindy.pritchett04
    edited May 2016
    My favorite that physicians seem to "get" is the following:

    Anoxic encephalopathy = CC (similar to the permanent state that occurs for
    pt's that are "down" > 6 minutes before CPR initiated)
    Metabolic encephalopathy due to hypoxemia = MCC (usually reversible - see
    it often in those pt's that present w/ acute resp failure - resolves when
    the underlying oxygenation issues are corrected)

    MD's often use these terms interchangeably, despite the fact that they
    represent different scenarios and have different impact in the coding
    world.

    Good luck with your meeting tonight!!

    Cindy Pritchett, RN, BSN, CCDS
    MedPartners CDI Consultant
  • jolene.filejolene.file
    edited May 2016
    Below are some examples of sepsis, renal failure and diabetes codes without specificity & than with further specificity changing the DRG. These examples show difference in SOI/ROM & DRG assignment. If you want, you can add your own DRG- wt/$$'s as it is different for each facility. Hope this is helpful for your presentation. GOOD LUCK!

    2 SEPSIS Examples of how documentation can change the DRG

    Example #1 Example #2
    038.0 - Strep septicemia 038.0 - Strep Septicemia
    482.30 - Strep pneumonia 995.92 - Severe sepsis
    402.91 - HCVD w CHF 785.52 - Septic shock
    428.0 - CHF, unspecified 482.30 - Strep pneumonia
    428.31 - Ac Diastolic CHF 402.91- HCVD w CHF
    428.0 - CHF, unspecified
    96.71 - Vent.96 hrs
    96.04- Insert, ET

    3- Major, Severity of Illness 4- Extreme, SOI
    3- Major, Risk of Mortality 4- Extreme, ROM

    DRG – 871 DRG – 870


    RENAL FAILURE Documentation examples which impact SOI/ROM & reimbursement

    Example #1 Example#2

    586 - RF, unspecified 584.6 - ARF, w tubular necrosis
    250.00 - Diab, unspecified 250.42 - DM, II, uncntrld w ren manifestations
    428.0 - CHF, unspecified 428.33 - Diastolic HF, acute on chronic
    585.5 - CKD, stage V


    2 - Moderate, Severity of Illness 3- Major, SOI
    2 - Moderate, Risk of Mortality 2- Moderate, ROM
    DRG – 684 DRG – 682


    DIABETES Documentation Examples which impact SOI/ROM:
    Example #1 Example#2

    250.00 - DM, unspecified 250.42 - DM, Type II, uncntrlld, w CKD
    585.9 - CKD, unspecified 585.5 - CKD, Stage 5
    403.90 - Htn+CKD, unspecified 404.91 – HCVD & CKD c CHF
    428.0 - CHF, unspecified 428.31 - Diastolic, HF, acute

    1- Minor, Severity of Illness 2- Moderate, SOI
    2- Mod., Risk of Mortality 3- Major, ROM
    DRG – 639 DRG – 698

    Jolene File,RHIT,CCS,CPC-H,CCDS
    Documentation Improvement Specialist-Coder
    Hays Medical Center
    jolene.file@haysmed.com
  • CLINDOCSPECLISTCLINDOCSPECLIST
    Thank you for all of the examples. Either thru this site or straight to my email. They are exactly what I needed! Thanks so much!!

    Rebekah Foster RN CCDS
    Kaweah Delta Medical Center
    400 W. Mineral King
    Visalia, CA 93291
    559-624-5085
    rfoster@kdhcd.org
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