Presenter: Aziz Ansari, DO, FHM
Summary: With the implementation of ICD-10, correct and specific documentation to ensure proper patient diagnosis categorization has become increasingly important. Hospitalists are urged to understand the impact CDI has on quality and reimbursement.
Quality Impact: Documentation has a direct impact on quality reporting for mortality and complication rates, risk of mortality, as well as severity of illness. Documenting present on admission (POA) also directly impacts the hospital-acquired condition (HAC) classifications.
Reimbursement Impact: Documentation has a direct impact on expected length of stay, case mix index (CMI), cost reporting, and appropriate hospital reimbursement.
- Be clear and specific.
- Document principle diagnosis and secondary diagnoses, and their associated interactions, are critically important.
- Ensure all diagnoses are a part of the discharge summary.
- Avoid saying “History of.”
- It’s OK to document “possible,” “probably,” “likely,” or “suspected.”
- Document “why” the patient has the diagnosis.
- List all differentials, and identify if ruled in or ruled out.
- Indicate acuity, even if obvious.
This presenter also reviewed common CDI opportunities in hospital medicine.
Note: This discussion was specific to the needs of the hospital patient diagnosis and billing, and not related to physician billing and CPT codes.