The Coding Corner

Diagnosis Capture and Documentation Complete the Patient Visit

Patient Risk Adjustment Factor (RAF) is reset annually on January 1, 2021. Accurate diagnosis coding and documentation contribute to a complete picture of patient health status. Complete documentation supports the patient medical status and diagnosis captured. The following support best practice to follow for complete visit documentation:

Elements of good clinical documentation

When documenting, it is useful to keep in mind the potential audience – clinical staff, other providers, payers and administration. This will help achieve clarity and allow you to focus on the details that are most relevant to include.

  • The basics of documentation:
    • Date, time and signature.
      • Timing of events and review is crucial in putting together the information regarding a patient’s health.
    • Include your name and title, add the names and titles of others present at the encounter.
    • Document immediately or as soon as possible after care is provided.
    • Prompt documentation reduces the risk of forgetting key details, and ensures all other team members are aware of any changes to a patient’s condition or management of care.
    • If you are returning to the patient’s notes later, document clearly in the heading that it was documented in retrospect with current date and time.
    • Document legibly.
    • Be thorough, accurate and objective.
    • Only use approved abbreviations
      • It is better to use to no abbreviations at all to avoid confusion.
      • If an addendum is made, communicate the change in documentation to other team members and clinical staff. Sign off any addenda with the time, date and full details.
    • Documentation mistakes
      • If a mistake is made, correct it with a single strikethrough, clearly sign and date the correction.
  • Documentation Examples:
    • Documenting a face-to-face visit based off time:
      In the office, a physician selects the level of service based on face-to-face time, when more than 50 percent of that time is spent discussing with the patient and family the diagnosis, prognosis, risk and benefits, instructions for management, and education. You can count only face-to-face time.
      An example of documenting based off time: “I spent 30 minutes with the patient and 50% of time was spent counseling and reviewing plan of care.”
    • Documenting a Telehealth visit:
      The technology used to conduct the visit via video/audio, the location of the provider conducting the visit, the patient name and location, include others on the video visit such as parent, spouse or care manager, verbal patient consent to have the visit conducted via telehealth video/audio (HIPAA compliant platform). The rest of the documentation will follow a face-to-face encounter requirements.
    • Documenting a telephone visit:
      It is important to document phone conversations with other medical teams and relatives of patients or clinical staff involved in the care of your patient.  After the phone conversation, write a note clearly stating who was involved in the conversation including their role. Document the clear question that was posed, and summarize the main information and points that were gained from the conversation. It’s important to note the pager number/telephone number of the person who was contacted to facilitate further contact if they need to be contacted again.
    • Important Areas of Documentation:
      • Principal diagnosis – the condition which after investigation was found to be the cause for the admission.
      • Co-morbidities – any conditions present on admission and treated. These conditions resulted in a change to the patient’s treatment, care or length of stay.
      • Complications – conditions which arose during the admission and affected the patient’s treatment and length of stay.
      • Procedures – surgical, non-operative, diagnostic, therapeutic procedures which required anaesthesia, sedation or injected contrast.

Please contact Shawn Bromley at 978-236-1704 or if you would like more information related to diagnosis capture and/or documentation requirements.

2020 OIG Workplan

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