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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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