In reviewing the medical record the coder notes disconnect between the physician documentation and the CDS documentation. Initial physician documentation indicates pneumonia with later documentation indicating acute bronchitis. The CDS worksheet indicates acute bronchitis. Was the pneumonia ruled out? Did the CDS obtain pertinent information about the patient’s diagnosis while attending physician rounds? Is there an outstanding query to clarify whether the pneumonia was ruled out?
Here are my thoughts…
- While code assignment may not be based on CDS documentation, many CDS have the opportunity to attend physician rounds and ultimately obtain pertinent information about the patient’s diagnoses and treatment plans. Information obtained very often creates a query opportunity to clarify and/or specify clinical documentation.
- Reach out to CDS to determine if information was obtained indicating the pneumonia was ruled out and if a query response is pending.
- Communication between the CDS and Coder ensures completeness of clinical documentation and coding accuracy.
CDS and coder communication is vital to the success of a Clinical Documentation Improvement Program (CDIP). The CDS worksheets serve as a valuable tool to coders and should be available to them for review at the time of discharge coding.
What are your thoughts?