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Think ‘specificity’ when documenting these seven diagnoses


Avoid denials by using these checklists for seven key primary care disease states.

Diagnosis codes convey the reason for the visit, and they also capture risk-something that many payers increasingly consider when calculating reimbursement. It’s important for physicians to ensure that the information they document is as specific and complete as possible, said Terri Thomas, RHIA, clinical documentation specialist in San Leandro, Calif., who spoke during AAPC’s HEALTHCON, April 8-11 in Orlando, Fla.

HEALTHCON offers educational sessions and networking opportunities for medical coders, billers, payer representatives, practice managers, attorneys, physicians, and other healthcare business professionals.

Accurate and complete documentation ultimately reduces denials, said Thomas. Translation? Physicians retain the revenue they generate.

Unspecified diagnosis codes often wreak havoc on cashflow because many payers simply deny them, said Thomas. “We need to be as specific and compliant as possible. That’s one of the reasons why we moved to ICD-10,” she said.

Thomas discussed these seven diagnoses and provided checklists of what physicians should document to avoid denials:

1. Anemia

• Any association with chemotherapy, neoplasms, drugs, chronic kidney disease, end-stage renal disease, or other chronic disease, when applicable

• Due to bleeding (including the site), when applicable

• Specificity (i.e., acute, chronic, or acute on chronic)

•Type (e.g., deficiency, aplastic, pernicious, or postoperative)

2. Asthma

• Any related tobacco use, dependence, or exposure

• Any chronic signs and symptoms

• Medication noncompliance, when applicable

• Presence of chronic obstructive pulmonary disease or bronchitis, when applicable

• Severity (i.e., mild intermittent, mild persistent, moderate persistent, or severe persistent)

• Triggers or environmental risk factors

• With or without acute exacerbation



3. Bronchitis

• Type (i.e., acute or chronic)

• Infectious agent (i.e., viral, bacterial, or obstructive)
• Associated conditions/contributing factors (e.g., influenza, pneumonia, or emphysema), when applicable

• Tobacco use, abuse, dependence, or exposure, when applicable

4. Chronic obstructive pulmonary disease

• Body mass index

• Smoking status, including history of smoking, when applicable

• Use of home oxygen, BIPAP, or CPAP, when applicable

• With acute exacerbation, hypoxemia, bronchitis, asthma, emphysema, or upper respiratory infection, when applicable

5. Congestive heart failure

• History of myocardial infarction, coronary artery bypass graft, or smoking, when applicable

• Medication noncompliance, when applicable

• Presence of heart disease, bradycardia, heart block/type, arrhythmia, or diabetes, when applicable

• Severity (i.e., acute, chronic, or acute on chronic)

• Type (i.e., systolic, diastolic, left, right)

• Use of home oxygen, when applicable

• With hypertension or renal failure, when applicable

6. Diabetes

• Long-term insulin use, when applicable

• Manifestations and complications (e.g., nephropathy, retinopathy, osteomyelitis, and vascular disease), when applicable

• Medication noncompliance, when applicable

• Presence of secondary diabetes and cause (e.g., due to neoplasm, steroid-induced, or adverse effect of drugs), when applicable

• Relationship between diabetes and cellulitis, when present

• Type (i.e., Type 1 or Type 2)

7. Hypertension

• Exposure to environmental tobacco smoke, when applicable

• History of myocardial infarction, coronary artery bypass graft, or any other cardiac condition, when applicable

• Medication noncompliance, when applicable

• Relationship with chronic kidney disease, congestive heart failure, or both, when applicable

• Tobacco dependence, use, or history of tobacco use, when applicable

• Type (i.e., emergency, urgency, or crisis)

In addition to capturing specificity, physicians must also ensure that they document all conditions that co-exist at the time of the encounter that require or affect patient treatment or management, said Thomas. This includes chronic conditions treated on an ongoing basis.

Coders are ethically obligated to query physicians when documentation is conflicting, ambiguous, incomplete, or inconsistent, said Thomas. They’ll also query when clinical indicators-but no diagnosis-is documented in the record. Physicians can mitigate these queries and protect revenue by taking the time to learn the specificity that’s required for code assignment, she said.

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