Pediatric Coding Alert

Question: When I audit my physicians' subsequent hospital care notes, I frequently find notes that don't tell much about the patient's condition since the previous visit. The pediatrician might document something like, "Patient doing well." I'm afraid such notations won't meet the requirements of an interval history. How can I get the physicians to write notes that will stand upon review?Iowa SubscriberAnswer: Since subsequent hospital care is on the Office of Inspector General's list of codes with high error rates, you're right to clean up your physicians' documentation now. When documenting interval history, ask your physicians to begin by answering two questions, suggested Kerin Draak, MS, RN, WHNP-BC, CPC, CEMC, COBGC, in "Hospital Coding ... Making the Rounds" at the 2010 American Academy of Professional Coders Annual Conference in Jacksonville, Fla. Why is the patient there? How has the condition changed since yesterday? If the physician answers the questions, the [...]