As physicians we frequently document past medical conditions with the phrase “history of…”. An example of this would be:
John Doe is a 54 yr old man with history of congestive heart failure who presents with worsening shortness of breath and increased leg swelling.
Though this documentation makes sense to any physician reading this it is not correct by CMS coding guidelines.
According to CMS coding guidelines “history of…” is referring to a condition that is no longer receiving any treatment.
For example 38 yr old man with a history of right tibial fracture in 1995 now presents with fever cough and expectoration. The history of tibia fracture indicates that the patient is no longer receiving treatment for the tibial fracture and is therefore appropriate documentation.
Another example: Jane Doe is a 67 yr old female with a history of hypertension presents with chest pain and is on metoprolol would not be correct as the hypertension is still being treated with the metoprolol even if it is controlled. This distinction is very important to correctly attribute the severity of illness for your patient.
A common mistake is to use the term “history of CHF…” This should be documented as “known CHF currently compensated..” or uncompensated as the case may be.
Centegra Health has partnered The Advisory Board Company to launch an ICD-10 Physician Documentation Education in October 2014.
Join us for a clinician-led introduction to the importance of ICD-10 and documentation improvement. This session will be focused on how simple word choice has a dramatic impact on the perceived acuity of our patients. Specifically, attendees will benefit from:
Getting credit where credit is deserved: accurate reflection of SOI, ROM, and quality scores
Strategies for improved documentation supporting SOI and ROM for today that will ease the transition to ICD-10
We provide excellent care to our patients. This effort is not about changing the way we practice medicine, or demanding that we document more; rather, it’s about getting credit for all that you do and helping us document in a way that captures all the good work we do now as well as in the ICD-10 environment.
Thank you in advance for taking the time to help Centegra achieve our quality goals.
Kumar Nathan, MD VP, Clinical Effectiveness
Irfan Hafiz, MD VP, Medical Affairs
7 to 8am
Internal Medicine (Internal Medicine, Hospitalists, Family Medicine, Gastroenterology, Hepatology)
There are updates to the 2 midnight macros for documentation. All future macros will begin with a period (.). This will allow for consistent naming. The previous 2 midnight macro will continue to work as well.
The patient is expected to need 2 midnights of inpatient care for the management of (add diagnosis) that is complicated by (add co-morbidities), and who has a significant risk of (add complications) if not hospitalized.
The patient’s (add S & S or Diagnosis) improved after (add outline of treatment) in less than 2 midnights. Therefore, the patient is being discharged (add date) to (add destination) to follow up with Dr. (add physician) in (add # days) days.
Macros are a fast consistent way to add information to a template. Typing the shortcut will expand to the text that corresponds to it. The parts of the boilerplate text that may need to be edited appears in brackets. Note to keep the naming of the macros different from nonmacro text they often will begin with a period (.).
Below is an example of how to add a macro to a template:
Type the macro into the template and then hit the space bar or the enter key.
For this example the Congestive Heart Failure macro will be used.
The macro for Congestive Heart Failure is “.chf”.
Text will populate. Edit the text within the brackets for an appropriate statement for the patient.
A full list of common macros can be found at Macros