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.
Below is a link to the CDI Tip of the Month. This month the CDI tip is Pneumonia.
Below are tips provided by Centegra’s CDI team:
For a complete list of Documentation Tips, click here.
Please view the tips below brought to you by our CDI team:
Congestive Heart Failure
On April 27th & May 26th Centegra’s HIM department conducted a presentation Kicking-off ICD-10. Dr. Janowtiz, from BCBS, also presented on May 26th regarding ICD-10. Below are the links to the presentations by Centegra HIM and Dr. Janowitz.
ICD-10 Overview by: Centegra Health System
ICD-10: Preparing for the Challenges Ahead by: Robert Janowitz, MD
In order to ensure capture of current diagnoses they must be documented within the progress notes AND the discharge summary. Diagnoses pertinent to the current visit must be documented in progress notes and carried through to the discharge summary. Including all diagnoses preceded by the words “ possible, probable, resolved, resolving, suspected, improved, improving, likely”.
For a printer friendly version please click here.
Attention Office Managers/Coders
UPDATE: Session is Full
What: Kick Off to ICD-10
Where: FOR THOSE THAT HAVE RSVP’D:NEW LOCATION 213 FRONT STREET IT CONFERENCE ROOM #5 MCHENRY
When: Monday, April 27, 2015; 12pm-1pm
*Box Lunch Provided*
There will be monthly ICD-10 learning sessions. Please contact Danette Santana, Physician Outreach
(815)788-5859/ email@example.com, for more information.
CDI queries are now electronic. The queries will now show up in a physician’s deficiency tab under Missing Text.
Please fill out the information at the space provided at the bottom of the document. Click into the box to input information before completing the deficiency.
Below is an example of what the queries will look like.
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For questions or concerns, please contact the EMR Physician Support Liaisons at (815)-759-4330.