Coding, Classification & Reimbursement

Subject: Dr's notes versus Clinical Evidence

1.  Dr's notes versus Clinical Evidence

Posted 14 days ago

We have a quandary.   Dr. says a patient has new compression fracture of the thoracic spine following a fall.   Radiology exam shows only OLD fractures.   With the new guidelines I know we can code a diagnosis based on the doctor's notes.  However, if t do code according to the Drs. note. and the chart gets audited, I'm afraid it will all be denied based on no clinical evidence.    I would appreciate any input on this issue.

Thanks in advance. 



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Jean Uhlenkamp
Clinical Documentation Improvement Specialist
St. Anthony Regional Hospital
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2.  RE: Dr's notes versus Clinical Evidence

Posted 14 days ago

Hi Jean:

That is a tough one. Wondering if you can provide some background info.  What was the reason for patient seeking medical attention? Was it acute back pain? Was it to work up the reason for the fall? Is there any indication that the MD reviewed the results of the radiology exam? Was there an ortho or other specialist consult? Sometimes, the MD will disagree with the radiologists reading, so I'd look for other clues in the documentation. Sometimes they state that as per their read (this is not always done), they disagree with the radiologist. At my facility, the MD will copy/paste the pertinent info into their note, but on occasion, they may disagree with the findings, especially if an orthopedic/neuro/neurosurg MD is consulting- they will usually go with the specialist's assessment. But they would address that in the body of the note/assessment. If the attending states acute back pain due to new compression fracture after a fall and specifically notes the radiology findings, you may not need to query. However, if you are this uncomfortable with the situation, you may have to query for confirmation given the documentation discrepancy, especially if there is no reasoning in the attending MD documentation. Just my take.

Hopefully others will chime in as well.

 

Good luck on this one-



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Jodi Kingley, CCS
Inpatient Coder
Princeton HealthCare System
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3.  RE: Dr's notes versus Clinical Evidence

Posted 14 days ago
Thanks for the input Jodi.   Yes, the patient is an elderly female who presented to the ER following a fall in her home.  She had acute pain (rated as a 6) upon presentation but following Toradol in the ER she had no more pain.    Her pain was noted to be 0 for 6 hours after admission and she has gotten no other pain meds.   We are calling the doctor and telling him that if the chart got audited it would likely be denied without further clinical support.   I think he is ordering an MRI so we will look for those results.


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Jean Uhlenkamp
Clinical Documentation Improvement Specialist
St. Anthony Regional Hospital
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4.  RE: Dr's notes versus Clinical Evidence

Posted 14 days ago
​I am assuming that the patient was seen in the ER, discharged and you are now in the coding process.

If the physician orders an MRI now, those results would not have been available to him/you at the time of the ER visit and cannot be used now to code that visit.

So 'Looking for those results' will not help you.      or   is the patient currently hospitalized ?

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Julianna Perez
Manager, Medical Records
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5.  RE: Dr's notes versus Clinical Evidence

Posted 14 days ago
​She is still a patient on the Med/Surg floor.

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Jean Uhlenkamp
Clinical Documentation Improvement Specialist
St. Anthony Regional Hospital
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6.  RE: Dr's notes versus Clinical Evidence

Posted 13 days ago
​Hi Jean!

The documentation will be key -  did the physician describe her pain level prior to presentation in the ED?  Do the nurses notes concur with the
physician documentation; i.e., "acute pain relieved with Toradol" or something similar?  Any social factors that might have precipitated the
presentation?    Agree that the imaging studies do not always demonstrate fractures, so the provider's documentation must support the rationale for the dx of acute fracture.

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Mary Meysenburg, MPA, RHIA, CCs
NHIMA Coding Roundtable Chair
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7.  RE: Dr's notes versus Clinical Evidence

Posted 10 days ago
​Thanks Mary!  I did discuss this with him and he said that the patient had significant increase in her pain following a fall at home.  She was in acute pain in the ER (level 7) but after one dose of Toradol her pain went to a 0 and has been there for over 48 hours with no further pain meds.  After speaking with him I've asked him to be sure to document that he feels this patient has had an acute fracture despite the x-ray evidence and why he feels that way.   Hoping that will be enough.   He has an MRI ordered this morning so hoping that will give us some help as well.

THANKS!

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Jean Uhlenkamp
Clinical Documentation Improvement Specialist
St. Anthony Regional Hospital
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8.  RE: Dr's notes versus Clinical Evidence

Posted 13 days ago
​Wonderful.  Perhaps this test will aid the physician in documenting a definitive diagnosis.

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Julianna Perez
Manager, Medical Records
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9.  RE: Dr's notes versus Clinical Evidence

Posted 13 days ago

Hello,

I would query MD to clarify conflicting documentation within the patient record, noting in the query his written diagnosis and the radiology report diagnosis.

 

Thank You,

Linnette Wert RHIT, CCS

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10.  RE: Dr's notes versus Clinical Evidence

Posted 13 days ago
Dear Jean,

I think the protocol is to code after the test is performed and the report is read. In this case the doctor ASSUMED that the fracture was new based on the conversation and exam performed on the patient. However, it seems according to the radiologic study performed that the patient did not fall "hard enough" to have fractured his/her thoracic spine and therefore a thoracic spinal fracture would not be an appropriate code in this case.

Jodi Miller, RHIT, CCS

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Jodi Miller, RHIT, CCS
Outpatient Coder/Abstractor
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11.  RE: Dr's notes versus Clinical Evidence

Posted 10 days ago
​I am in the CDI role so I'm trying to get the best information I can while the patient is in.   He did order an MRI which did show a new, acute fracture of the thoracic vertebrae so we have the information that we need to code that diagnosis definitively.

Thanks so much!

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Jean Uhlenkamp
Clinical Documentation Improvement Specialist
St. Anthony Regional Hospital
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