Wiki Compliance question, symbols

[Love Coding!]

Hello,

I am looking for an answer to this question. In regards to inpatient services, does anyone know if Medicare (Noridian, Palmetto, Trailblazer) has a rule when it comes to using symbols (+ -, ↑, ↓ ) to describe the patients diagnosis with out writing out the diagnosis, examples below... are these acceptable to use? Would anyone know where I can find answer to this? Thank you!

Hyperpotassemia - ↑ K
Hypertension - ↑ BP
Hypotension - ↓ BP

 

[btadlock1]

Hello,

I am looking for an answer to this question. In regards to inpatient services, does anyone know if Medicare (Noridian, Palmetto, Trailblazer) has a rule when it comes to using symbols (+ -, ↑, ↓ ) to describe the patients diagnosis with out writing out the diagnosis, examples below... are these acceptable to use? Would anyone know where I can find answer to this? Thank you!

Hyperpotassemia - ↑ K
Hypertension - ↑ BP
Hypotension - ↓ BP

I would say yes - they're easy to understand...this is from Cigna Governmental Services:
http://www.cignagovernmentservices.com/partb/claims/cert/Articles/cope9014.html
"CHECK YOUR RECORDS FOR THE FOLLOWING …
Records are legible; all abbreviations and symbols will be easily recognized by reasonable clinicians..."

 

[RebeccaWoodward*]

Hello,

I am looking for an answer to this question. In regards to inpatient services, does anyone know if Medicare (Noridian, Palmetto, Trailblazer) has a rule when it comes to using symbols (+ -, ↑, ↓ ) to describe the patients diagnosis with out writing out the diagnosis, examples below... are these acceptable to use? Would anyone know where I can find answer to this? Thank you!

Hyperpotassemia - ↑ K
Hypertension - ↑ BP
Hypotension - ↓ BP

In the event that a carrier/auditor does not recognize your physicians symbols, you should incorporate these symbols into your company compliance plan and place these symbols in your compliance plan/manual. When the carrier requests the medical record (for whatever reason) you will want to send them a copy of these symbols and how they translate into the physicians terminology. When our provider creates a unique abbreviation/symbol, we place this information into the physicians file and have the provider sign off on this information. Leaves little room for misinterpretation.