Documenting Manifestations: “Connect” with an Accurate Payment

Over the years, we’ve seen it all when it comes to physician documentation.  One physician in a group insisted that if she wrote all the conditions on one line, they were connected.  Her partner’s charting habit was using slash marks between the conditions, stating this implied a causal relationship between the diagnoses. Breaking them of these idiosyncrasies took some work!

We all know that diabetes can sometimes cause other conditions, from eye problems to kidney disease.  Sometimes these conditions are unrelated to the underlying diabetes; more often than not, however, the diabetes actually caused these issues.  It’s important that clinician documentation bear out the connection with actual words.

Documenting “CKD III secondary to Type II Diabetes” isn’t the same as charting “DM/CKD” or ‘DMII, retinopathy.’  Words such as ‘due to,’ ‘secondary to (or using the 2o),’ ‘caused by’ or even ‘with’ are all handy (and required) in conveying a causal relationship between conditions.  Not only is this accurate charting of the patient’s diagnoses, but it makes a difference to the practice’s reimbursement under risk adjustment.

The use of electronic health records will help providers to chart more accurately because the systems are not able to handle creative documentation, but growing pains will be significant and reimbursement could suffer if your clinicians aren’t writing properly right now.

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