Medical Record Content 1

Administrative 2
Clinical 2
Tools To Help You Code 2

Step 1: Review The Registration Page 3 Step 2: Review The Content Of The Medical Record 3 Step 3: Review All Reports 4 Step 4: Progress Notes 4 Step 5: Review All Tests 4 Step 6: Review Provider Orders 4 Step 7: Review Medication Administration Record (MAR) 4 Step 8: Review Discharge Summary (DS) 5 Step 9: Code Assignment 5 * 8 Steps to Code: 5 * General Reporting Requirements 5 * Selection of Principal and Secondary Diagnosis(es) 6 Step 10: Always… 7

Medical Record Content

The patients’ Medical Record (MR) or chart also known as an Electronic Health Record (EHR), or Electronic Medical Record (EMR) is the source for abstracting your medical codes for provider reimbursement.

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The diagnoses, procedures, drugs, supplies, tests, services and equipment are all coded for reimbursement to a provider for services rendered during patient care in an office or other medical facility such as a hospital, or ER etc.

Data is administrative and clinical.

Administrative

Name
Personal Identification number
Health care facility identification number
Admission and Discharge dates
Provider identifications
Age
Gender
Race/Ethnicity
Date of birth
Address
Email
Phone number
Insurance information
Consents

Clinical

Diagnoses
Procedures
Tests, x-rays or lab results
Services
Supplies
Drugs
Past medical personal and family histories

Tools To Help You Code

Up to date coding manuals CPT, ICD-10-CM, ICD-10-PCS and HCPCS or an online encoder
Up to date guidelines for each code set
Access to American Hospital Association (AHA) Coding Clinic
Medical dictionary
Specialty reference books
Drug information
Human anatomy references
Coder Toolbox- coding resources online

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Joining a Coding Community to ask coding questions to peers

An incomplete medical record can cause inaccurate coding and can affect a provider’s bottom line and cause compliance issues such as fraud and abuse concerns. The Joint Commission states that patients’ histories and physicals (H&Ps) must be completed within 24 hours, and operative reports must be completed immediately, but the overall record must be completed within 30 days, and often a discharge summary (DS) will fall within this time period. You may at times need to query for more information.

Most employers use an encoder to help coders code a medical record, but a good coder should know the basics and how and where to locate any information needed in any manual. This can help a coder spot more easily any errors and make any needed queries and or addendums to adjust the record to reflect the most accurate information needed to code correctly before using an encoder. The Office of Inspector General (OIG) suggests not to rely 100% on computerized encoders and indicates coders should have access to current coding manuals.

Step 1: Review The Registration Page

It contains patient identification information, insurance data and clinical data such as admitting and final diagnosis. Take special note of patients’ gender, age, length of stay, and anything that relates to the complexity of the diagnosis and treatment.

Step 2: Review The Content Of The Medical Record

☐ Physical examination (PE) ☐ History of Present Illness (HPI) ☐ Chief Complaint (CC) ☐ Review Of Systems (ROI) ☐ Personal, Family and Social History (PFSH) ☐ Emergency department and consult reports ☐ Principal Diagnosis- Review this information to determine the providers principal diagnosis which is the condition after study chiefly responsible for the patient’s admission and any secondary diagnoses or other diagnoses that may affect the patients care such as complications and or comorbidities that the patient received treatment. ☐ Preoperative and Postoperative diagnosis ☐ Treatment plan ☐ Principal Procedures- Review this information to determine the provider’s principal procedure which can be diagnostic, therapeutic or to treat a complication. It is the procedure to be determined to be most closely related to the principal diagnosis.

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Step 3: Review All Reports

☐ Operative procedures ☐ Special procedures- Cardiac catheterization, upper and lower endoscopies, bronchoscopies with or without biopsies. ☐ Anesthesia ☐ Pathology ☐ Special consents

Note: Remember to sequence definitive before diagnostic procedure codes.

Step 4: Progress Notes

Includes- admit note, notes related to the patient’s condition and progress, responses to treatments, and a discharge note. Note any significant findings and resolutions of problems or complications.

Step 5: Review All Tests

☐ Laboratory- Chemical, analyses, cultures, body fluids (blood, urine, stool, and pus) ☐ Radiology- x-rays-Computerized Tomographic scan (CT), Nuclear Medicine studies, Magnetic Resonance Imaging (MRI), Arteriograms, etc. ☐ Special tests-Electrocardiogram, echocardiogram, Cardiac stress test, etc. ☐ Abnormal findings

Step 6: Review Provider Orders

Determine the treatment to the patient and directions to the nursing staff and ancillary personnel that direct all treatments and medications to the patient.

Step 7: Review Medication Administration Record (MAR)

Provides documentation of drugs given to the patient to help support the diagnosis- drug names, dosages, times given and routes of administration (Mouth, injection, intramuscular or intravenous).

Long Term Drugs (LTD).

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Step 8: Review Discharge Summary (DS)

Summary of the patient’s course in the hospital, condition upon discharge, discharge instructions, and follow-up plan for future treatment. It includes all final diagnoses as well as all procedures.

Step 9: Code Assignment

Assign codes by following:

Uniform Hospital Discharge Data Set (UHDDS)
CPT, ICD-10-CM, ICD-10-PCS and HCPCS Code sets- using each code set conventions, guidelines and sequencing rules.

Remember to code to the most specific codes.

Remember Medicare and or specific payer guidelines/rules for your provider and other payers.

8 Steps to Code:

Identify the main term(s) and sub term(s) for procedures, tests, services, equipment and supplies from the medical record.
Locate the main term(s) in the Alphabetic Index by service or procedure, anatomic site, condition or disease, synonym, eponym, or abbreviation.
Review any sub term(s) under the main term in the index.
Follow any cross-reference instructions such as SEE
Verify the chosen code in the Tabular list for further coding specifics such as code first or code additional. (Never code directly from the Index alone as you may miss important things that may lead you to choose a more specific code choice).
Refer to any Tabular list instructional notations such as conventions, notes and related guidelines.
Assign codes to the most specific code choice (CPT may require a modifier and both CPT and ICD-10-CM may require an unlisted or unspecified code choice).
Code all diagnoses, procedures, supplies, tests, services and equipment until all elements are completely identified.

General Reporting Requirements

POA indicator reporting is mandatory for all claims involving inpatient admissions to general acute care hospitals or other facilities.

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POA is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA.

A POA Indicator must be assigned to principal and secondary diagnoses and the external cause of injury codes. CMS does not require a POA Indicator for an external cause of injury code unless it is being reported as an “other diagnosis.”

If a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current official coding guidelines, then the POA Indicator would not be reported.

Selection of Principal and Secondary Diagnosis(es)

Inpatient admission always governs the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

The UHDDS definitions are used by hospitals and include all non-outpatient settings The UHDDS definitions also apply to hospice services (all levels of care).

Coding conventions in the ICD-10-CM, the Tabular List and Alphabetic Index take precedence over these official coding guidelines.

Symptoms, signs, and ill-defined conditions from Chapter 18 are not to be used as principal diagnosis when a related definitive diagnosis has been established.

When there are two or more interrelated conditions (such as diseases in the same ICD-10-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.

When two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.

When two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided and the Alphabetic Index and/or Tabular list or other coding guideline does not provide sequencing direction then either diagnosis may be sequenced first. If one of the diagnoses results in extensive or non-extensive O.R. procedure unrelated to the principal diagnosis MS-DRGs 981-989), the diagnosis that does not result in the unrelated DRG would be principal diagnosis.

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The Medicare Claims Processing Manual Chapter 3 states that in order to appropriately identify the severity of the patient and the resources utilized, sequence the principal diagnosis, the condition that results in the higher relative weighted assignment.

Additional diagnosis as defined by the UHDDS as all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay and diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.

UHDDS defines all significant procedures to be reported. A significant procedure is defined as surgical in nature, carries a procedural risk or carries an anesthetic risk or requires specialized training.

The principal procedure is defined by the ICD-10-CM guidelines as the procedure that is most directly related to the principal diagnosis.

It is the coders responsibility to determine what the documentation in the medical record equates to in the ICD-10-PCS manual definitions.

Areas of the medical record that contain acceptable physician documentation to support code assignment include the discharge summary, current history and physical, ER record, physician progress notes, physician orders, physician consultations, operative reports, anesthesia notes, and physician notations of intra-operative occurrences.

Diagnoses in other documentation such as but not limited to nurse notes, EKGs, nutritional evaluations, pathology -radiology-lab, and other ancillary reports not documented by the provider directly participating in the care of the patient must be queried for confirmation of the condition except for BMI or pressure ulcer stages can be provided by clinicians. Use the documentation of these to confirm things such as sites and locations.

In inpatient admissions any diagnosis documented at the time of discharge is qualified as probable, suspected, likely, questionable, possible, still to be ruled out, compatible with, consistent with or other similar terms indicating uncertainty, code the condition as if it existed or was established.

Step 10: Always…

☐ Remember the conventions, guidelines and sequencing rules. ☐ Make sure the documentation supports your coding. ☐ Remember the coders motto, “If it is not documented it was not done.”

If the documentation is not supporting the diagnoses, you may need to query the provider to clarify a diagnosis or to add supporting documentation through a provider added addendum to the record to support the diagnosis intended and codes chosen in case the provider is ever audited as diagnosis codes establish the medical necessity for services and reimbursement.

Sources used to help compile this information: HCA, CMS, LWW

Certification Coaching Organization LLC https://www.cco.us/

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Abstracting The Basis Of Coding

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