Q&A: Physician abbreviations and queries

Q: I have a situation where providers are using abbreviations such as AHRF for acute hypoxic respiratory failure, ADHF for acute decompensated heart failure, etc. Can I code these conditions, or do I need to query to clarify the abbreviation? 

A: When providers utilize an uncommon abbreviation, we should look at our internal facility-based abbreviation list or guidance from our health information department or medical record committee.  If the abbreviations are on the facility-approved abbreviation list, then they can be coded as such. If they are not, the provider must write the full name of the abbreviation out one time within the record prior to utilization—this is best practice. You will still need to obtain the type of heart failure in this case, so it may also be a good teaching moment for the provider: requesting that they document the term in full prior to abbreviation use. As always, no assumptions can be made.

Editor’s note: Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, CDI education director at ACDIS/HCPro, answered this question. Contact her at deanne.wilk@hcpro.com