Thread by @Dr_Oubre

I studied >200 pages on Clinical Documentation Improvement.

(So you don’t have to)

Here are 3 documenting tips so you (and your hospital) get paid.

(Repost with actual 🧵 this time)

The problem?

• Hospitals are PAID off documentation (even surgeries)
• Documentation needs to be specific & accurate
• Doctors language ≠ coding language

Let’s dig in…

1. You CAN code off of probability.

You’re a doctor. You can make a clinical diagnosis. You do not need perfect objective data to prove it.

“Presumed” or “suspected” is okay.

(For inpatient only. Sorry outpatient docs)

An example…

We ALL know how unreliable sputum cultures are.

Treating someone in the hospital for “Pneumonia” is “Simple Pneumonia” in coding language. A simple pneumonia doesn’t need treatment in a hospital.

But you’re using cefepime, Zosyn, etc…

What are your treating?…

Are you treating for a gram negative pneumonia?

If so, “Suspected gram negative pneumonia” is okay.

I’ll have a dedicated thread on Simple vs Complex PNA coming soon.

Let’s move on…

2. LINK with words

Many diagnoses / codes need a cause. But there are words that are more clear than others.

Example: Right hemiparesis after 2019 stroke.

Coders can’t assume. You MUST be precise.

So what’s the problem?

Did they coincidentally develop right sided weakness at some point following a stroke?

Or was it DUE TO the stroke?

Words to AVOID:
• After
• in the setting of

Words to use:
• due to
• related to
• as a result of

These are clearer in linking the two diagnosis.

3. Be specific. Learn the language.

If you’re like most doctors, you’re not great at describing what you’re treating outside of a firm diagnosis.

You know the WHY. You just don’t know the WHAT language.

Example…

78 year old female with end-stage dementia is brought in by family because they can no longer take care of her.

“She’s too weak,” they say.

Your admission diagnosis: Generalized weakness.

There’s a problem here.

So, I have a challenge for you….

When you use a diagnosis, imagine that diagnosis for a healthy 30 year old.

30 year old with weakness?

Maybe she’s just feeling run down, but still able to work and take care of her kids.

Is this what you mean for that 78 year old?

OF COURSE NOT

But a diagnosis (code) is not contextualized by age. It stands alone.

So let’s see how we can describe her situation more accurately…

Age related debility? That sounds better.

And Functional quadriplegia? (she’s bedbound)

What about her multiple pressure ulcers?

Oh and her underlying end-stage dementia, CKD, DMII, severe malnutrition, etc…

That paints a better picture doesn’t it?

And look! You didn’t have to pretend it was
due to a UTI and give unnecessary antibiotics! @kjdelay1

#antibioticstewardship all because you had better language.

@kjdelay1 So now you / the hospital get paid for the complex mental work to take care of this extremely medically complex patient that required intensive hospital resources, medical decision making and disposition planning.

That’s not “up-coding.” It’s accurate.

@NorwoodCDI

@kjdelay1 @NorwoodCDI In summary,

1. Its okay to use diagnoses of probability
2. Link diagnoses
• “Due to”
• “Related to”
• “As a result of”
3. Be specific. Learn the right language.

@kjdelay1 @NorwoodCDI That's a wrap!

If you enjoyed this thread:

1. Follow me @Dr_Oubre for more of these
2. RT the tweet below to share this thread with your audience