HCPro, JustCoding Inpatient - 2015 Issue 8 (February)
Take a closer look at SOI, ROM though a case study
February 25th, 2015
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Article Overview
This article explains how a case study is used to show query opportunities for documenting patient severity of illness and risk of mortality. It is aimed at CDI specialists, coders, and documentation improvement staff who want to understand how clinical indicators, physician documentation, and reported diagnoses can affect DRG-related assessment. The article also touches on broad topics such as hypertension, renal dysfunction, brain injury, and ICU-level care as they relate to documentation review.
Why This Topic Matters
Accurate documentation of severity and mortality risk can affect how a patient’s condition is represented in coded data and DRG-based classification. The article helps readers recognize when additional documentation review may be warranted in complex inpatient cases.
Article Sections
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Case study overview
Introduces the patient scenario and explains that the example is being used to identify documentation opportunities in a complex inpatient case.
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APR-DRGs
Describes the general APR-DRG framework for severity of illness and risk of mortality and places the case within that context.
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Query opportunities
Reviews broad categories of documentation gaps that may prompt separate queries in the case study and discusses how those gaps can affect case representation.
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Querying correctly
Summarizes how coders and CDI staff can evaluate clinical indicators and treatment information when preparing documentation queries.
What You Will Learn
- How a case study can be used to identify CDI query opportunities
- How severity of illness and risk of mortality are discussed in an APR-DRG context
- How clinical indicators and treatment information support documentation review
- How coders and CDI specialists approach complex inpatient documentation
- How query development fits into broader documentation improvement efforts
Who Should Read This
- Clinical documentation improvement specialists
- Medical coders
- HIM professionals
- Inpatient coding auditors
- Documentation specialists
Codes Discussed
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