Tag Archives: CDI

When is it appropriate to document “history of…”?

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.

Reminder: Electronic CDI Queries

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.
CDIClick to enlarge

For questions or concerns, please contact the EMR Physician Support Liaisons at (815)-759-4330.

ICD-10 Physician Documentation Education in October 2014

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







10/20/20147 to 8amInternal Medicine
(Internal Medicine, Hospitalists, Family Medicine, Gastroenterology, Hepatology)
Centegra Hospital-Woodstock3701 Doty Rd., WoodstockA
10/20/201412 to 1pmAllergy/Immunology
(Allergy, Immunology, Infectious Disease, Rheumatology)
Front St. IT Conference Room213 Front St. McHenry6
10/20/20146 to 8pmGeneral Surgery
(General; Trauma;Cardiac; Cardiothoracic; Plastic; Colorectal; Pancreatic; Hepatic; all other surgical specialties)
Centegra Hospital-Woodstock3701 Doty Rd., WoodstockA
10/21/20147 to 8amCritical Care
(Intensivists, Pulmonology, Anesthesia)
Centegra Hospital-Woodstock3701 Doty Rd., WoodstockA
10/21/201412 to 1pmInternal Medicine
(Internal Medicine, Hospitalists, Family Medicine, Gastroenterology, Hepatology)
Front St. IT Conference Room213 Front St. McHenry6
10/21/20146 to 7pmPediatrics
(Pediatrics, Newborns, Pediatric Surgery)
Centegra Hospital-Woodstock3701 Doty Rd., WoodstockA
10/22/20147 to 8amEmergency Department
(ED and Urgent Care)
Centegra Hospital-McHenry4201 Medical Center Dr., McHenryD
10/22/201412 to 1pm CardiologyFront St. IT Conference Room213 Front St. McHenry6
10/22/20146 to 8pmObstetrics and Gynecology
(Obstetrics, Gynecology, Surgical, Gynecology, Gynecologic Oncology)
Centegra Hospital-McHenry4201 Medical Center Dr., McHenryD
10/23/20147 to 8am Orthopedics/Orthopedic SurgeryCentegra Hospital-McHenry4201 Medical Center Dr., McHenryD
10/23/201412 to 1pmNeurosurgery
(Neuro-Oncology Surgery, Neurosurgery-spine, Neurosurgery-vascular)
Front St. IT Conference Room213 Front St. McHenry6
10/23/20146 to 7pm CardiologyCentegra Hospital-Woodstock3701 Doty Rd., WoodstockA

2 Midnight Rule Macro Update

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.

This is a link to the complete list of macros

Macros for Templates

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

Michael Millare and Prapti Desai are available for any questions or requests via email or the Physician Support Line (815) 759-4330.

Tips on documenting AMS

AMS is a term with many potential clinical meanings, but is considered “confusion” when the patient’s medical record is coded.

To ensure the complexity of care rendered is accurately reported, please consider using the following definitions, when appropriate, rather than the term “altered mental status”.

  • Encephalopathy – Nondegenerative diffuse brain disorder secondary to an underlying process, eg. sepsis, toxic, metabolic, hypertensive, hepatic, anoxic. The hallmark is altered mental state.
  • Delirium – Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. Disorganized thinking, agitation, misperceptions of sensory stimuli, and visual hallucinations.
  • Dementia – Progressive decline in mental processes. Memory impairment , cognitive disturbances, and a disturbance in executive function.
  • Stupor – State of baseline unresponsiveness that requires repeated application of vigorous stimuli to achieve arousal.
  • Coma – State of unresponsiveness in which the patient lies with eyes closed and cannot be aroused, even with vigorous stimulation.
  • TIA – Brief cerebral, spinal, or retinal ischemia without acute infarction. Cerebral Embolus or Thrombus (without infarction) is usually an underlying cause of TIA.
  • Stroke – Neurological Symptoms with evidence of stroke on neuroimaging
  • Aborted Stroke – “Stroke in Evolution” – Transient neurologic symptoms due to ischemia with a normal MRI. Therapeutic efforts (e.g. tPA) may play a role.
  • Psychosis –Disturbance in perception of reality. Delusions, hallucinations, and thought disorganization.


The diagnoses for inpatients can be written as “possible”, “probable”, “suspected”, “likely” or “rule out”

Clinical Documentation – when should “history of…” not be used

“History of” terminology should not be used if condition is currently being treated. “History of” implies the condition no longer exists and treatment is not currently being performed.

Instead document “Diabetes, being followed by Endocrinologist, no complaints at this time, compensated on Insulin”.

Commonly non documented conditions

Remember to document the presence of any medically created openings or limb loss.

Any patient with any of these conditions has a higher severity of illness than a patient without one.

Artificial openings

  • Gastrostomy V44.1
  • Colostomy V44.3
  • Tracheostomy V44.0
  • Ileostomy V44.2


  • BKA V49.75
  • AKA V49.76
  • Foot V49.73
  • Toe V49.71 or V49.72

Vascular conditions

  • AAA – Abdominal aortic aneurysm – 441.1 (w/o repair)
  • Aortic Atherosclerosis – 440.0

Documentation of metastatic disease

When documenting a case with metastatic disease remember to document to location of the mets.

“Colon cancer with metastasis to bone” codes higher severity of illness than “colon cancer with mets” without mention of location.

Btw do not document “history of metastatic colon cancer” – this cannot be coded at all. By the rules a condition with “history of” is no longer present and is not requiring current treatment.

General rule of thumb is if a patient is receiving active treatment for a condition then it should never be documented as “history of”.