MRA Thought of the Day–Clinical Documentation versus Clinical Evidence

Lynn Salois, RHIT, CCS, CDIP, Director of Coding Lynn Salois, RHIT, CCS, CDIP, Director of Coding

An elderly patient with a past medical history of CHF presents to the hospital with dyspnea and hyponatremia. Review of the history and physical indicates the patient’s daily Lasix dose was increased recently. What to do? Dig deeper!

Upon further review, progress notes revealed that the patient has been non-compliant with a low sodium diet with excess water ingestion. The physician continuously documents sodium levels, noting daily improvement and indicates hyponatremia due to Lasix diuresis and dietary non-compliance. Documented treatment plan is gentle hydration to correct sodium. The progress notes also indicate metabolic encephalopathy secondary to hyponatremia. There is no clinical documentation reflecting the patient’s mental status.

My Thoughts…

In reviewing the clinical documentation supporting the diagnoses there is noticeable differences in the clinical evidence supporting the two diagnoses. For example, the clinical evidence supporting the hyponatremia includes; abnormal lab values, etiology, patient’s progress and treatment plan. In comparison, there is minimal clinical evidence supporting the metabolic encephalopathy.

Here are some ideas for next steps:

Discuss the lack of supporting clinical evidence for the physician documented metabolic encephalopathy with the Clinical Documentation Specialist (CDS) involved in the case. The CDS and the physician should discuss the documentation issue and the need for supporting clinical evidence of code assignment.
Raise a RAC red flag! CMS recently issued the revised Recovery Auditors Scope of Work. The revised scope of work will include Clinical Validation Audits. The audits will determine whether or not the clinical evidence in the medical record supports the physician documented diagnoses.
What would you do?

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