In the January 2018 edition of the peer-reviewed Journal of the American Health Information Management Association (JAHIMA), UASI corporate trainer Natalie Satori, MEd, RHIA, published an article that seeks to clear up some of the confusion surrounding clinical criteria, as they pertain to coding guidelines and clinical validation specifically for sepsis.
As health information management (HIM) and coding professionals know, sepsis is just one of many chronic conditions for which there are published sets of clinical criteria, and there has historically been variance in reporting diagnoses based on those clinical criteria.
Some coders have reported them based solely on clinical criteria being met, even in the absence of a provider’s specific statement in the medical record that the patient exhibits that condition. Others have reported such conditions only if the provider has documented them explicitly in the medical record.
Natalie’s piece seeks to clarify what coders should do in cases where provider documentation and clinical criteria don’t match up.
More Provider Education Is Needed to Ensure Documentation Matches Clinical Criteria
A new rule in Section I of the 2017 ICD-10-CM Official Guidelines for Coding and Reporting states:
“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”
Coders should not add a diagnosis to a chart, based on clinical criteria having been met, without specific supporting documentation from the attending physician. These dilemmas provide an opportunity for clinical documentation improvement (CDI) and stronger clinical validation.
“Organizations continue to see a rise in audit activities and subsequent clinical denials on the basis of established clinical definitions and criteria for sepsis … Providers must therefore have a mechanism to ensure both correct coding and reporting as well as complete clinical documentation. The goal for medical staff is to develop a clinical policy which includes the new definitions as well as documentation expectations.”
CDI Specialists Have a Strong Role to Play in Provider Education
In developing such a policy, healthcare organizations should work with medical staff to provide additional opportunities for education about existing clinical criteria and ongoing changes that might be made to them.
CDI specialists are uniquely positioned to provide feedback to physicians to improve not only their charting, but their performance on the patient care unit.
“Clinical criteria should be easily and rapidly obtained to allow practitioners to better identify patients with suspected infection that are likely to progress to a life-threatening state.”
Helping physicians to better understand subtleties in the clinical criteria, she intimated, could allow a medical staff to develop protocols that would identify and treat sepsis earlier and, hopefully, achieve more positive outcomes.
UASI Can Help Your Organization to Ramp Up Its CDI Efforts
Accurate, concise and timely clinical documentation is essential to hospital and provider organizations’ ability to attain quality patient outcomes. With risk-based and performance-based reimbursement models becoming the norm, the stakes are high both clinically and financially. There are significant penalties for failing to correctly document everything, every time.
UASI can help. We provide comprehensive, client-focused CDI consulting and ongoing training and education services so our own coders and those of our clients can keep up with ongoing changes and clarify the gray areas (like those around sepsis). Our recommendations are based on CDI best practices, national benchmarking and official regulatory sources.
We’ll tailor toward your organization’s and staff’s unique needs, with basic, advanced and topic-specific education for coders, CDI specialists, physician CDI advisors and physicians alike.
Contact us to find out how we can help your hospital or physician group improve its clinical documentation and coding today.