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Tips to Boost Your Documentation Process: Audit Protection

Posted on Wed, Jan 21, 2015
Tips to Boost Your Documentation Process: Audit Protection

By Timothy N. Brundage M.D., CCDs

Good documentation is important for new physicians as well as veteran caregivers. While documenting can seem like a very straightforward skill, there are often “best practices” that can be utilized. As a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, FL I write a “weekly documentation tip” email to help physicians improve their clinical documentation. I also share these documentation strategies with the residents I teach.

Documentation Tip: Audit Protection

Official coding guidelines support coding a diagnosis that is only documented once in the medical record. However, auditors increasingly deny diagnoses that do not flow consistently through the medical record to include the discharge summary. While it is not necessary for a physician to document the criteria used to make a 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.

ABOUT THE AUTHOR

Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, FL. 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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CDC: U.S. Life Expectancy Hits Record High of Nearly 79 Years

Posted on Sun, Oct 12, 2014
CDC: U.S. Life Expectancy Hits Record High of Nearly 79 Years

Lifestyle changes cited as reason for gains

WEDNESDAY, Oct. 8, 2014 (HealthDay News) -- Average life expectancy in the United States reached an all-time high of 78.8 years in 2012, the U.S. Centers for Disease Control and Prevention reported Wednesday. For people 65 years old in 2012, life expectancy was an additional 19.3 years, up slightly from the year before. Women age 65 and older in 2012 can expect to live another 20.5 years, while men may get around an additional 18 years.

Death rates for eight of the 10 leading causes of deaths declined significantly, according to the report. Heart disease deaths dropped 1.8 percent; cancer deaths dropped 1.5 percent; deaths from chronic lower respiratory diseases went down 2.4 percent; stroke deaths declined 2.6 percent; Alzheimer's disease deaths dropped 3.6 percent; diabetes deaths decreased by 1.9 percent; deaths from influenza and pneumonia dropped 8.3 percent; and deaths from kidney disease declined 2.2 percent. Although the reasons aren't clear, suicides increased 2.4 percent in 2012 compared to 2011. At the same time, deaths from unintentional injuries remained the same.

In 2012, a total of 23,629 infants under age 1 year died. That was 356 fewer infants than in 2011, according to the report. The 10 leading causes of infant mortality in 2012, accounting for more than two-thirds of infant deaths, were the same as they were in 2011: birth defects, low birth weight, sudden infant death syndrome, maternal complications, unintentional injuries, umbilical cord and placental complications, bacterial infections, breathing problems, circulation problems, and newborn bleeding. Death rates among these conditions remained essentially unchanged. The one exception was deaths from sudden infant death syndrome, which dropped 12 percent.

"Americans are living longer and are more aware of preventing chronic diseases," the report's lead author, Jiaquan Xu, M.D., an epidemiologist at the CDC's National Center for Health Statistics, told HealthDay.

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