Hospital Outpatient Documentation Improvements May Be Required
Coders, physicians, and medical practice managers should review their documentation processes for possible outpatient documentation improvements, such as :
? Documentation of laterality ? fractures, breast biopsies, etc.
? Specific disease process ? pathological versus traumatic fracture
? Acuity ? chronic versus acute CHF, asthma, or bronchitis
? Listing current medications ? long-term use of anticoagulants or aspirin
? Mention of the type of imaging performed in interventional radiology procedures
In addition, when surgical interventions are performed, the LCDs generally require the surgeon to indicate which conservative treatments had been tried and what the results were of those attempts. Coders need to educate their physicians to document in the medical record for the visit where the decision for surgery was made all of the conservative treatments that have been tried prior to the decision for performing surgery. A brief summary of conservative treatments that failed should also be mentioned in the actual indications section of the operative report.
One aspect of specific documentation that gets overlooked is continued documentation of a condition. For example, after first being diagnosed, a breast cancer patient?s medical record will undoubtedly state which breast was involved. The breast biopsy report will naturally mention which quadrant was biopsied. Thus a carcinoma of the left upper outer quadrant would be coded C50.412. However, the order for the insertion of a central venous access to administer chemotherapy may only mention the indication as breast cancer, which will be coded with the non-specific code C50.919, Malignant neoplasm of unspecified site of unspecified breast. Depending on what procedure is performed and how the LCD is written, this type of documentation may not pass the LCD medical necessity edits.
Coders, physicians, and medical practice managers need to review their documentation to ensure that the documentation specificity carries forward though out the patient?s treatment for the disease treatment in order to ensure that nonspecific documentation and coding does not slip back into the medical record after the first diagnosis of the disease.