News: MAC notice underscores importance of good documentation through the medical record

CDI specialists ideally should review medical records in their entirety and clarify non-specific documentation for reasons other than just principal diagnosis or CC/MCC capture. This recently-released article by Medicare Administrative Contractor Trailblazer provides a great overview of different types of clarification that should be obtained on all inpatient admissions.

• Documentation of the patient’s condition
• The patient’s need for services and prior failed interventions
• A plan of care to address the patient’s specific healthcare needs
• The results of laboratory tests, signed radiology reports and diagnostic tests ordered by the physician
• The risk factors complicating the patient’s healthcare condition
• The patient’s response to:
  • Surgical procedures and medical interventions
  • Therapies
• Progress made in the patient’s condition and plan of care
• Description of setbacks in patient progress
• Any barriers to treatments, for example, complications that need to be addressed before other treatments may be initiated
• History and physical information and risk factors which influence physician treatment decisions that present risk and/or that reduces the improvement of the patient’s condition