Coding Corner: Optimizing Inpatient Documentation Through a Billing and Coding Lens | Karyn Hansen, MD

Karyn Hansen, MD

As a student and trainee, we are often taught to organize our thoughts and note writing using a systems-based approach. This approach works well to communicate with our co-clinicians, but often does not help our billing and coding specialist team. This can lead to loss of revenue or worse those pesky “coding inquiries!”

In current practice, progress notes are not only a daily update of a patient’s medical care but are also utilized as an important component of hospital and professional coding as well as quality metrics reporting. Every time a progress note is signed, and a corresponding inpatient professional charge is dropped, the charges should be associated with the correct diagnoses. How this is accomplished will depend on the EHR of the hospital system.

Ideally, a progress note would contain a running problem list with a daily update including an assessment and plan for each problem. This will allow for appropriate documentation as well as assist the hospital billing and coding team.

Example: A patient is admitted for inpatient chemotherapy management for an ovarian germ cell tumor. This patient would have a problem list including ICD-10 codes for ovarian cancer (C56.x) and chemotherapy management (Z51.11). Additional problems may be addressed during this admission and should be included in the problem list. These include diagnoses that speak to the complexity of patient care, such as malnutrition, obesity, hypomagnesemia, hypokalemia, or anemia.

Billing using the most specific available ICD-10 code from the start is always the best practice. It gives a better picture of the patient’s clinical record and it demonstrates to the insurance company the severity of the patients being seen. And the best part, it avoids those pesky coding inquiries after the fact!

From the example above, the ovarian cancer diagnosis could be right (C56.1), left (C56.2), or bilateral (C56.3), even when metastatic. Anemia could be acute blood loss anemia (D62), iron deficiency anemia (D50.8) or anemia due to antineoplastic chemotherapy (D64.81). Try to avoid diagnosis codes containing the word “unspecified.”

Diagnosis based inpatient documentation allows for appropriate communication with other clinicians as well as with our billing, coding, and compliance colleagues.

Karyn Hansen, MD, is a gynecologic oncologists at Trinity Health of New England in Hartford, CT.