Practice Management

“You have a pending query”

Specificity is essential in documentation and coding


Throughout medical training, you learn to write complete and detailed notes to communicate with other physicians. As a student and resident, you are praised when you succinctly analyze and address all patient problems while justifying your orders for the day. But notes do not exist just to document patient care; they are the template by which our actual quality of care is judged and our patients’ severity of illness is captured.

Dr. Geetanjali Rajda, medical director of clinical documentation and quality improvement for Mount Sinai Hospital, New York, and medical director for DRG appeals for the Mount Sinai Health System.

Dr. Geetanjali Rajda

Like it or not, ICD-10 coding, documentation, denials, calls, and emails from administrators are integral parts of a hospitalist’s day-to-day job. Why? The specificity and comprehensiveness of diagnoses affect such metrics as hospital length of stay, mortality, and Case Mix Index documentation.

Dr. Lida Fatemi, assistant professor at the University of New Mexico,  Albuquerque. She is director of documentation, coding, and billing for the division of hospital medicine at UNM.

Dr. Lida Fatemi

Good documentation can lead to better severity of illness (SOI) and risk of mortality (ROM) scores, better patient safety indicator (PSI) scores, better Healthgrades scores, better University Hospital Consortium (UHC) scores, and decreased Recovery Audit Contractor (RAC) denials as well as appropriate reimbursement. Good documentation can even lead to improved patient care and better perceived treatment outcomes.

Dr. Maria Reyna, assistant professor in the division of hospital medicine and medical director for clinical documentation and quality improvement at Mount Sinai Medical Center in New York City.

Dr. Maria Reyna

It is no surprise that many hospital administrators invest time and money in staff to support the proper usage of language in your notes. Of course, sometimes these well-meaning “queries” can throw you into emotional turmoil as you try to understand what was not clear in your excellent note about your patient’s heart failure exacerbation. In this article, we will try to help you take your specificity and comprehensiveness of diagnoses to the next level.

Basics of billing

Physicians do not need to become coders but it is helpful to have some understanding of what happens behind the scenes. Not everyone realizes that physician billing is completely different from hospital billing. Physician billing pertains to the care provided by the clinician, whereas hospital billing pertains to the overall care the patient received.

Below is an example of a case of pneumonia, (see Table 1) which shows the importance of specificity. Just by specifying ‘Aspiration’ for the type of pneumonia, we increased the SOI and the expected ROM appropriately. Also see a change in relative weight (RW): Each diagnosis-related group (DRG) is assigned a relative weight = estimated use of resources, and payment per case is based on estimated resource consumption = relative weight x “blended rate for each hospital.”

Table 1. Specificity in coding

In addition to specificity, it is important to include all secondary diagnosis (know as cc/MCC – complication or comorbidity or a major complication or comorbidity – in the coding world). Table 2 is an example of using the correct terms and documenting secondary diagnosis. By documenting the type and severity of malnutrition we again increase the expected risk of mortality and the severity of illness.

Table 2. Secondary diagnoses

Physicians often do a lot more than what we record in the chart. Learning to document accurately to show the true clinical picture is an important skill set. Here are some tips to help understand and even avoid calls for better documentation.

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