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Documentation Tip of the Week: GI Bleed

Posted on Wed, Nov 25, 2015
Documentation Tip of the Week: GI Bleed

Our weekly feature of documentation tips for clinicians.

By Timothy Brundage, MD

Choose words carefully to capture the true severity of illness (SOI) for your patient:

 
No SOI Moderate SOI High SOI
Stool with +occult blood
 
GI Bleeding
Melena
GI Bleeding from
DEFINED site (e.g.
PUD)
GERD
Esophagitis
Acute esophagitis
Esophageal ulcer
Esophageal ulcer with
bleeding or Mallory-
Weiss


Did you Know? “BRBPR” does not have a code. Consider documenting “hematochezia” or “Lower GI Bleeding” to effectively reflect SOI in coding language.



Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.
 

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Documentation Tip of the Week: Diabetic Coma

Posted on Wed, Nov 11, 2015
Documentation Tip of the Week: Diabetic Coma

Our weekly feature of documentation tips for clinicians.

According to the Mayo Clinic:
 

  • A diabetic coma is a life-threatening complication that causes unconsciousness
  • Unconsciousness codes to COMA in ICD-10
  • Definition of unconsciousness:
    • Not knowing or perceiving : Not aware
    • Free from self-awareness

Diabetic Coma:
  • Altered mental status should make the physician consider the diagnosis of diabetic coma in the uncontrolled diabetic with hypo or hyperglycemia.



Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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Documentation Tip of the Week: Tips for Avoiding an Audit

Posted on Wed, Nov 04, 2015
Documentation Tip of the Week: Tips for Avoiding an Audit

Our weekly feature of documentation tips for clinicians.

By Timothy Brundage, MD


  • Official coding guidelines support coding a diagnosis that is only documented once in the medical record. However, auditors are increasingly denying diagnoses that do not flow consistently through medical record to include the discharge summary.

  • While it is not necessary for a physician to document the criteria he or she used to make the diagnosis, it will reduce the potential for denial.

  • Conflicting documentation between different providers increases the likelihood of denial.

  • Whenever possible, the attending physician should clarify any inconsistent documentation.


Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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Documentation Tip of the Week: Stroke for ICD-10

Posted on Wed, Sep 30, 2015
Documentation Tip of the Week: Stroke for ICD-10

Our weekly feature of documentation tips for clinicians.

By Timothy Brundage, MD

ICD-10 is coming October 1st! Are you ready?

Key points in the documentation of stroke:

  • Laterality & Site (identify affected vessel)
  • Etiology (occlusion, hemorrhage, thrombosis, stenosis)
  • Underlying conditions (HTN, Atrial Fibrillation, etc.)
  • List any alcohol, drug, tobacco use/abuse/dependence
  • List tobacco exposure (second hand, occupational)

Hemiplegia is a comorbidity/complication (CC)
  • Document if dominant side for ICD-10

Document “history of stroke” only in the PMHx portion

“Sequelae” of stroke is preferred if there is a manifestation due to current/previous stroke:
  • Hemiplegia, as a sequelae of stroke
  • Aphasia, as a sequelae of stroke
  • Ataxia, as a sequelae of stroke



Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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