Wiki Auditing diagnoses in an EHR?

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acerway

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I need some help from the experts on diagnosis documentation using an EHR.

Our pediatric & family practice providers pick all of their diagnoses. We have a great EHR program that makes it very easy to search all possible diagnoses by keywords. The problem is that the providers sometimes tend to be a little quick and lazy about picking the correct diagnosis, and some don't know the coding guidelines for things that are outside the ordinary.

As a result, half of the diagnoses they choose are the "other" or "unspecified" codes. I review the more complicated claims before they go out and often have to add or correct diagnoses. However, the providers rarely name their diagnosis in the assessment area of the chart. There's only a diagnosis code with the description listed in the ICD book, so I'm constantly having to "query the provider" for clarification.

When I perform audits I'm not sure what to think about that. From an experienced auditor's point of view, would that stand up as acceptable documentation?

I fear this is going to create even more problems as we get into ICD-10...:eek:
 
The American Medical Association (AMA) and The Centers for Medicare and Medicaid (CMS) indicate:

“Clear and concise medical record documentation is critical to providing patients with quality care and is required in order for providers to receive accurate and timely payment for furnished services. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. Section 1862 of the Social Security Act stipulates that payment can only be made for care that is reasonable and necessary.”

“Medical records chronologically report the care a patient received and are used to record pertinent facts, findings, and observations about the patient’s health history. Medical record documentation assists physicians and other health care professionals in evaluating and planning the patient’s immediate treatment and monitoring the patient’s health care over time. Health care payers may require reasonable documentation to ensure that a service is consistent with the patient’s insurance coverage and show the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or that services furnished have been accurately reported with an accurate assessment, clinical impression, or diagnosis that best meets the patient's condition."

You should have meetings with the doctors to discuss these issues and ramp up your processes, protocols and policies for this AND ICD 10 before your revenue stream drops dramatically because of the specificity that ICD 10 will require. United Healthcare is predicting a 30% plus drop in revenues once ICD 10 starts with this revenue drop lasting up to six months. Will your business be able to afford this significant drop in revenue? Be proactive and good luck
 
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