Posted: May 15th, 2023

The physician documents that the patient has pneumonia

For each of the following scenarios, explain the risk to coding compliance and a possible corrective action. What types of auditing or monitoring activities could be undertaken to verify success of the described corrective action?

25 points (5 points each)

Consider the following documentation errors that could result in coding errors:

The physician documents that the patient has pneumonia. Documentation elsewhere in the medical record indicates that the patient may have a bacterial pneumonia. The physician fails to respond to repeated query attempts. The coder assigns ICD-9-CM code 486, “Unspecified pneumonia.”
The physician documents that the patient suffered “both bone fracture” in the right lower arm. An open reduction with internal fixation is performed. The coder is unable to assign an accurate code because the documentation does not indicate the specific site, for example, proximal end, distal end, or shaft.
Under the “review of systems” in an evaluation and management (E/M) note, the physician documents, “Pertinent to headache addressed in HPI, others negative.” The physician should indicate the specific systems reviewed and all others negative. The phrase “others negative” should not be used to indicate a complete review of systems.
A patient has a diabetic ulcer of the left ankle that requires debridement. The documentation of the debridement does not indicate the deepest level debrided or the method of debridement (excisional or nonexcisional). The documentation does not indicate whether the patient has Type 1 or Type 2 diabetes. The coder is unable to correctly identify the type of diabetes, the extent of the debridement, and whether the debridement was excisional or nonexcisional.
The physician documents the removal of a 2.0-cm benign lesion of the upper arm. The physician documents that “adequate margins” were taken to ensure complete removal. The coder assigns the code for a 2.0-cm lesion removal, as the physician failed to document the specific excised diameter.

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Documentation error: The physician documents “pneumonia” without specifying whether it is bacterial pneumonia.
Risk to coding compliance: Assigning an unspecified code (ICD-9-CM code 486) may result in inaccurate representation of the patient’s condition, leading to potential reimbursement issues and incorrect statistical data.
Possible corrective action: The coder should make repeated attempts to query the physician for clarification on the type of pneumonia. If the physician does not respond, the coder should escalate the issue to the appropriate clinical documentation improvement (CDI) specialist or a designated physician advisor. The corrective action would involve obtaining a clear diagnosis from the physician and updating the documentation accordingly.
Auditing or monitoring activities: To verify the success of the corrective action, the coding department or compliance team can conduct regular audits. They can review a sample of cases where there were queries made for documentation clarification. The audits would ensure that there is evidence of query attempts, proper escalation processes, and updated documentation reflecting the correct diagnosis.

Documentation error: The physician does not specify the specific site of a “both bone fracture” in the right lower arm.
Risk to coding compliance: Without the specific site (e.g., proximal end, distal end, or shaft), accurate coding is not possible, which may lead to incorrect billing, potential denial of claims, and inaccurate representation of the injury.
Possible corrective action: The coder should query the physician for clarification on the specific site of the fracture. If the physician is unresponsive, the coder should consult with the orthopedic department or seek guidance from a physician advisor to determine the appropriate code. The corrective action involves obtaining the necessary information to accurately code the fracture site.
Auditing or monitoring activities: To verify the success of the corrective action, regular audits can be conducted to review a sample of cases involving fractures. The audits would assess whether there were queries made for site clarification, evidence of consultation with the orthopedic department or physician advisor, and accurate coding based on the updated documentation.

Documentation error: The physician uses the phrase “others negative” to indicate a complete review of systems in an E/M note.
Risk to coding compliance: Using a generic phrase like “others negative” does not provide the specific systems reviewed, which may result in incomplete documentation of the patient’s condition and inaccurate coding for the E/M services provided.
Possible corrective action: The coder should educate the physician on the documentation requirements for a complete review of systems. The physician should be encouraged to explicitly list the specific systems reviewed and document them as “negative” individually. The corrective action involves improving the documentation practices to meet coding compliance standards.
Auditing or monitoring activities: To verify the success of the corrective action, regular audits can be conducted on E/M notes. The audits would assess whether the documentation includes a comprehensive review of systems with specific systems listed and documented as “negative.” The audits would provide evidence of improved documentation practices and compliance with coding guidelines.

Documentation error: The documentation of a diabetic ulcer debridement lacks information on the deepest level debrided, method of debridement, and the patient’s diabetes type.
Risk to coding compliance: Incomplete documentation regarding the extent of debridement, the method used, and the type of diabetes can lead to inaccurate coding, potentially resulting in reimbursement issues and incorrect representation of the severity of the patient’s condition.
Possible corrective action: The coder should initiate a query to the physician to obtain the missing information. If the physician is unresponsive, the coder should consult with wound care specialists or the healthcare team to gather the necessary details. The corrective action involves obtaining comprehensive documentation to accurately code the debridement procedure and indicate the type of diabetes.
Auditing or monitoring activities: To verify the success of the corrective action, regular audits can be conducted on cases involving diabeticulcer debridement. The audits would assess whether there were queries made for missing information, evidence of consultation with wound care specialists or the healthcare team, and accurate coding based on the updated documentation. The audits would provide insights into the improvement in documentation practices and compliance with coding guidelines.

Documentation error: The physician documents the removal of a 2.0-cm benign lesion without specifying the excised diameter.
Risk to coding compliance: Without the specific excised diameter, accurate coding is not possible, which may result in incorrect billing, potential denial of claims, and inaccurate representation of the procedure performed.
Possible corrective action: The coder should query the physician for clarification on the excised diameter of the lesion. If the physician does not respond, the coder should consult with the pathology department or a designated physician advisor to determine the appropriate code based on available information. The corrective action involves obtaining the necessary details to accurately code the lesion removal procedure.
Auditing or monitoring activities: To verify the success of the corrective action, regular audits can be conducted on cases involving lesion removal. The audits would assess whether there were queries made for excised diameter clarification, evidence of consultation with the pathology department or physician advisor, and accurate coding based on the updated documentation. The audits would provide evidence of improved documentation practices and compliance with coding guidelines.