Every month, hospital-based health information management professionals must walk the thin line of ensuring adequate revenue is generated from submitted claims while maintaining quality during coding and pre-bill audits.
While neonatal abstinence syndrome is a serious condition, the lack of a standard clinical definition makes it difficult for providers to recognize the symptoms and accurately diagnose and treat newborns. If the syndrome is not recognized, and thus not documented, then the correct diagnosis code will not be assigned—which in turn impacts the state and national statistics regarding this syndrome.
Assigning newborns temporary names at birth is a common practice for hospitals. As a result, a large volume of patients with similar identifiers could potentially result in duplicate records and increase the risk for sentinel events (e.g. circumcision performed on wrong patient).
The evidence for almost any diagnosis can be argued regarding the given variables within a record. This applies to both CDI professionals seeking to add diagnoses and auditors seeking to remove them.
The challenge for clinical documentation improvement specialists is in determining if the condition is an expected outcome of the procedure or patient’s disease process, or if it is an actual post-operative complication.
The minimum data set (MDS) coordinator is a key player in a skilled nursing facility’s (SNF’s) team.