Table 2 shows the frequency of patient and physician characteristics presented by agreement between ED adjudicated diagnosis and NACRS main-position algorithm. Medical charts are important for documenting patients clinical status, communication among healthcare providers and have medicolegal value. In order to replicate the Canadian coding standards, only documentation dated and timed prior to the disposition from the ED was evaluated.12. Administrative data are continuously generatedat a cost to the healthcare systemto help decision-makers monitor, evaluate and plan the provision of health services as well as for research. Finally, many coders are faced with rule-out diagnosis when the patient is receiving follow-up or aftercare. In suspected patients with TIA and minor stroke presenting to the ED, physician documentation was the dominant factor in coding accuracy, supporting the concept that physicians are active participants in administrative data coding. Ethics approval: University of Calgary Institutional Review Board for Research (REB15-2943). 82F history of AF, transient aphasia and right arm weakness. An Italian study evaluating physicians intercoder agreement for stroke codes defined an expert coder as a neurologist who underwent at least three half-day or full-day ICD-coding training courses.22 In comparison, Canadian coding specialists are trained in a 2-year postsecondary education programme.23 Prior publications have shown that education programmes on documentation and inpatient coding processes improve the accuracy of diagnoses, comorbidities and complications coding in administrative data on both medical and surgical services.24 25, Our results are consistent with other studies reporting the influence of physician factors on administrative data coding accuracy. OBrien Institute for Public Health, Calgary, Alberta, Canada, 4 The primary outcome was disagreement between adjudicated ED diagnosis and the main-position NACRS algorithm. There were 78 (18.7%) charts with documented uncertain diagnosis, and 73 (17.5%) charts had no definite diagnosis. The study population was obtained from two observational studies on the diagnosis of TIA and minor stroke versus stroke mimic using serum biomarkers and neuroimaging, and most patients were discharged from a single university teaching hospital, limiting the generalisability of our results to other jurisdictions and healthcare models. Improving their accuracy is in the best interest of patient care. When linkage to multiple ED visits occurred, including between-ED transfers, the last visit prior to enrolment was retained for analysis. And the converse can also be true. Careers. Among 163 chart-adjudicated cases of TIA, there were 60 (36.8%) charts that were correctly coded as a TIA in the mainposition and there were 103 (63.2%) charts that were incorrectly coded as non-TIA. When evaluating the content of physician documentation, we determined whether there was documentation of a clear final diagnosis, documentation of uncertainty or a lack of a definite diagnosis. If the patient is no longer being treated for cancer and it is clearly documented that the patient no longer has cancer, only the history of cancer should be coded. This forces the coder to chase down physicians, spend time researching records, or try to think like an attending physician. ED, emergency department;NACRS, National Ambulatory Care Reporting System; TIA, transient ischaemic attack. Kidwell CS, Alger JR, Di Salle F, et al.. Diffusion MRI in patients with transient ischemic attacks, Transient ischemic attack--proposal for a new definition. The National Ambulatory Care Reporting System (NACRS) database contains discharge diagnoses for all ED visits in Alberta coded as one ICD 10th Canadian iteration (ICD-10-CA) code for the main problem per ED visit, up to 10 other problems codes.13 A prefix Q can be combined with any diagnostic codes in order to flag that the diagnoses were queried by the physician. government site. We defined abnormal imaging as presence of tissue ischaemia, intracerebral haemorrhage or evidence of vascular disease in the relevant territory (intracranial occlusion or50%stenosis and/or extracranial occlusion or50%stenosis or<50% in thepresence of an ulcerated plaque or thrombus). Provenance and peer review: Not commissioned; externally peer reviewed. WHO MONICA Project Principal Investigators. Among 417 patients included, the adjudicated diagnoses showed 163 (39.1%) TIA, 155 (37.2%) mild ischaemic strokes and 99 (23.7%) stroke mimics. The attending physiciannot the radiologistassigns the most accurate final diagnosis. Coders are mandated to exclusively use physician documentation to code diagnoses and comorbidities. The attending physician is the one who usually sees the entire picture, including the patients history, symptoms, laboratory findings, and other clinical indicators.
Administrative data codes were compared with the chart-adjudicated diagnosis to determine cases of misclassification by administrative data. We had limited information on individual physician or coder characteristics, such as their role (trainee, attending andsubspecialty), level of training and experience. While diagnostic uncertainty cannot be eliminated in clinical medicine, our study highlights the importance of clearly conveying the working diagnosis and outlining the thought process behind the investigations and management plan. Assaf AR, Lapane KL, McKenney JL, et al.. Possible influence of the prospective payment system on the assignment of discharge diagnoses for coronary heart disease, Coding for quality measurement: the relationship between hospital structural characteristics and coding accuracy from the perspective of quality measurement, Organisational factors affecting the quality of hospital clinical coding, Physician and coding errors in patient records, Inaccuracy of the International Classification of Diseases (ICD-9-CM) in identifying the diagnosis of ischemic cerebrovascular disease, Accuracy of administrative data for the coding of acute stroke and TIAs. FOIA For follow-up of a fracture, coders can use V54.X (other orthopedic aftercare) as the primary diagnosis, followed by a code for the fracture. National Library of Medicine Spellberg B, Harrington D, Black S, et al.. Capturing the diagnosis: an internal medicine education program to improve documentation, Effect of a documentation improvement program for an academic otolaryngology practice, Chart documentation quality and its relationship to the validity of administrative data discharge records, Assessing the accuracy of administrative data in health information systems, Agreement regarding diagnosis of transient ischemic attack fairly low among stroke-trained neurologists. Multivariable analysis showed that physicians diagnostic uncertainty was associated with disagreement, OR 3.71 (95% CI 2.16 to 6.36), whereas ongoing symptoms in the ED was associated with less disagreement, OR 0.32 (95% CI 0.20 to 0.51). The risk difference was 18.5%, suggesting that close to one in five charts with coding misclassifications could have improved accuracy if a definitive diagnosis was documented or uncertainty removed. AF, atrial fibrillation; CT/CTA, CT and angiography; ICD-10-CA, International Classification of Disease 10th Canadian iteration;MCA-M2, middle cerebral artery, M2 branch, MP, main problem; OP, other problem; TIA, transient ischaemic attack.
Once you communicate with the outpatient registration staff, provide regular reports to encourage their continued support. Interabstractor agreement between the two stroke neurologists was 76.7% (=0.50) for the diagnosis of TIA.
The onus is on the coder to know which symptoms are reimbursable and which are not. Nonetheless, it would still be up to the attending physician to make a definitive diagnosis. As a general rule, suspected conditions should never be coded in the outpatient setting. Vol. The radiologist may see something in the x-ray, though symptoms are minimal or nonexistent. Department of Radiology, University of Calgary, Calgary, Alberta, Canada, 6 Most of the incorrect coding was explained by cases of chart-adjudicated TIA that were incorrectly coded as non-TIA (103/122 84.4%). Radiology coders are trapped between radiologists and revenue, forced to balance the need for clinical data integrity with administrative demands for fewer denials and more accurate reimbursement. The term rule out is commonly used in outpatient care to eliminate a suspected condition or disease. ABCD2, Age, Blood pressure, Clinical, Duration, Diabetes;ED, emergency department;NACRS, National Ambulatory Care Reporting System. This resulted in a high proportion of cases with neurological consultations in the ED and limits the generalisability of our results to other settings. Canadian Institute for Health Information. Among 417 patients (39.1% TIA, 37.2% minor stroke and 23.7% stroke mimics), there were 122 cases of disagreement between adjudications and administrative data codes for the diagnosis of TIA. ED, emergency department;NACRS, National Ambulatory Care Reporting System. The risk difference was 18.5%.
sharing sensitive information, make sure youre on a federal We recorded whether neuroimaging was completed in the ED. None of these options is an efficient, long-term solution. Accessibility As per coding standards, we obtained the final diagnosis from the consultant or admitting services notes. ED, emergency department;NACRS, National Ambulatory Care Reporting System; TIA, transient ischaemic attack. Minor stroke is defined as National Institute of Health Stroke Scale score3. Univariable and multivariable logistic regression analysis (OR (95%CI)) of candidate predictors of disagreement between ED adjudicated diagnosis and NACRS coding among patients with a clear final diagnosis documented. Because we predicted the content of physician documentation to strongly influence coding accuracy, the logistic regression analyses were repeated in the subgroup of patients with a clear final diagnosis documented. Demonstration of cerebral ischaemia using magnetic resonance diffusion-weighted imaging in clinically-diagnosed patients with TIA is variable (30% to 70%) and associated with longer symptom duration.29 A tissue-based diagnosis for TIA has been proposed, where the diagnosis is defined by the absence of tissue ischaemia.30 However, because diffusion-weighted imaging is not routinely used in clinical practice, applying a tissue-based TIA diagnosis as reference standard would negatively impact the generalisability of our results. Frequency of baseline characteristics presented by agreement between ED chart adjudication and NACRS main-position algorithm, n (%). During the meeting, present a monthly report showing real-life examples of rule-out exams that did not meet medical necessity because of incomplete clinical documentation. For example, in a normal chest x-ray, the patient may have a clear chest upon radiological exam, and therefore the radiologist could only document rule-out or suspected pneumonia. 21 No. Among 254 chart-adjudicated cases of non-TIA (minor strokes or mimics), there were 235 (92.5%) charts that were correctly coded as a non-TIA in the mainposition and 19 (7.5%) charts that were incorrectly coded as a TIA. A good example is a radiological exam to rule out appendicitis. DOUBT is a neuroimaging study of patients with TIA, minor strokes and stroke mimics and enrols patients within 7 days after symptom onset. Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada, 5 The total number of incorrectly coded charts was 122. The study population was obtained from two ongoing studies on the diagnosis of TIA, minor stroke and stroke mimic. Having two or more vascular risk factors was statistically significantly associated with having a clear final diagnosis, but the magnitude of the association was small and the CIs were wide (OR 1.64 (95%CI 1.03 to2.63)). SPECTRA was funded by Genome Canada and Genome Alberta, and DOUBT was funded by the Canadian Institutes of Health Research.
The relative risk of disagreement between chart adjudication and administrative data coding when the final diagnosis was uncertain or absent was 1.82(1.36, 2.44) and the risk difference was 18.5%. Data accuracy can be influenced by physician factors, patient characteristics, as well as the patientphysician interaction. SBC contributed to the study concept and design, data interpretation, critical revision of the manuscript and supervision. 11 P. 5. All ED charts were manually reviewed by a stroke neurologist (AYXY), blinded to the administrative data coding, to obtain the ED clinical diagnosis. Documentation of diagnostic uncertainty and lack of a definitive final diagnosis were the only factors associated with thedisagreement between chart adjudication and administrative data for the TIA any-position algorithms(OR 3.16 (95%CI 1.82to 5.47)and 2.51 (95%CI 1.42to 4.45), respectively) and the cerebral ischaemia main-position algorithms (OR 3.26 (95%CI 1.93to 5.50) and 2.55 (95%CI 1.49to 4.37), respectively). ED, emergency department;NACRS, National Ambulatory Care Reporting System; TIA, transient ischaemic attack. Unfortunately, radiology coders are often caught in the middle with not enough information to code the attendings final diagnosis. Electronic health records have the potential to improve documentation quality with their advantage of being more standardised in structure and better data accessibility and readability, but their ability to truly improve data quality is still unclear.17 Further, current electronic record systems are designed to focus on document composition without facilitating data synthesis, which further increases the information burden physicians are face with.15 Resident physicians report spending more time inreading and documenting medical health records than being at the bedside and raise concerns over the lack of feedback on their charting.18 19 One solution is to encourage, teach and provide incentives for improving the quality of health records to avoid losing important messages in the noise.20 Specifically, data from the USA demonstrate that physicians do not receive adequate training in disease nosology and coding methods.21 In certain European countries, physicians are responsible for administrative data coding, but the degree of formal training is variable. Figure 2 shows the cases of disagreement between chart adjudication and the NACRS any-position algorithm. Funding: This work was supported by Alberta Innovates Health Solutions (AYXY holds a Clinician-Fellowship Award, grant number 201500087). PMC legacy view They may use laboratory or imaging reports to add specificity, but they cannot code a diagnosis unless it is documented by a physician. Disagreement between ED chart adjudicationand NACRS main-position algorithm for the diagnosis of TIA. We calculated the relative risk and risk difference of having a clearly documented final diagnosis and an accurate administrative data code. Also demonstrate the negative impact on reimbursement. MDH contributed to the study concept and design, data analysis and interpretation, critical revision of the manuscript and supervision. While this term works well for clinicians and supports medical-legal requirements, it wreaks havoc on radiology coders and radiology reimbursement. From a pure radiological perspective, it is not their responsibility to make a diagnosis, only to help rule out or verify something that is suspected by another clinician.
In clinical practice, physicians often infer diagnoses made by another physician even if it is not explicitly stated. Hotchkiss Brain Institute, Calgary, Alberta, Canada. Prospective studies evaluating the effects of techniques to improve physician documentation, such as education programmes, standardised discharge summaries or automated coding algorithms, on coding accuracy are needed. Univariable regression was used to evaluate candidate predictors of disagreement, and the significant variables were tested in a multivariable model to obtain an adjusted estimate of effect. If no consultant was involved during the ED visit, the final diagnosis was obtained from the ED physicians note. The site is secure. This handshake, or passing along of information, works well for clinicians. The study population was obtained from two ongoing Canadian studies: SPECTRA (Spectrometry for Transient Ischaemic Attack Rapid Assessment) and DOUBT (Diagnosis Of Uncertain-origin Benign Transient neurological symptoms). The new PMC design is here! In order to illustrate how quality of physician documentation may influence coding accuracy, table 1 shows the three different documentation styles of a hypothetical scenario: 82-year-old woman with history of atrial fibrillation presents with 15min of aphasia and family noted right hand clumsiness now resolved, examination normal. CT and angiography showed no acute ischaemia, but there is a left middle cerebral artery, M2 branch occlusion. ED charts were manually reviewed by a stroke neurologist to obtain the clinical diagnosis, patient characteristics and content of physician documentation. McCormick N, Bhole V, Lacaille D, et al.. Validity of diagnostic codes for acute stroke in administrative databases: a systematic review, The World Health Organization MONICA Project (monitoring trends and determinants in cardiovascular disease): a Major international collaboration. Next, find out which of these codes meet medical necessity edits for your local carrier. ABCD2, Age, Blood pressure, Clinical, Duration, Diabetes;ED, emergency department;NACRS, National Ambulatory Care Reporting System; TIA, transient ischaemic attack.
In the subgroup of patients with a clear final diagnosis documented (table 4), the association between clinical variables and administrative data accuracy start to emerge: ongoing symptoms in the ED and having a neurologist evaluation in the ED were associated with higher accuracy of coding and male sex was associated with lower accuracy. Ruling Out the Rule-Out Diagnosis Calanchini PR, Swanson PD, Gotshall RA, et al.. Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada, 3 Patient clinical characteristics, time of presentation (after-hours presentation is between 16:30 and 7:30) and stroke risk factors (history of ischaemic strokes or TIA, intracerebral haemorrhage, congestive heart failure, coronary artery disease, hypertension, diabetes mellitus, dyslipidaemia, atrial fibrillation, peripheral vascular disease and active smoking) were abstracted. Many organizations have addressed this problem through clinical documentation improvement teams. Strategies to improve chart documentation are predicted to have a positive effect on coding accuracy. Coding accuracy has been shown to be influenced by prospective payment systems,2 structural factors, such as the size, geographical location and specialty of the hospital or health organisation,3 4 coder characteristics, expertise, continuing education,4 as well as physicians.5 A reabstraction study of 1829 medical records from 21 Veterans Administration hospitals found that 62% of coding inaccuracies could be attributed to physicians missing or inappropriately including procedures and diagnoses, using inadequate terminology, and calling inactive diagnoses active.5 Inaddition, the accuracy of administrative data codes is dependent on the disease under study, the study time period, the International Classification of Diseases (ICD) iteration used,6 the case definition algorithm (choice of ICD codes and their positions)7 8 and the clinical setting.8 9. Johnsen SP, Overvad K, Srensen HT, et al.. Predictive value of stroke and transient ischemic attack discharge diagnoses in The Danish National Registry of Patients. The adjudicated diagnosis of TIA was made based on the WHO time-based criteria.11 For example, a patient with symptoms lasting <24hours but an MRI showing evidence of tissue ischaemia, like a small diffusion weighted imaging lesion, was adjudicated as a TIA and specifically not a stroke. HHS Vulnerability Disclosure, Help The https:// ensures that you are connecting to the We also evaluated predictors of documentation of a clear final diagnosis. This is consistent with a study conducted in the Stanford TIA Clinic that reported a 72% overall agreement among fellowship-trained stroke neurologists.28 The subjectivity in TIA diagnosis, especially during the initial health encounter, is impossible to eliminate. Other transient cerebral ischaemic attacks and related syndromes. Physicians report that the Assessment and plan section is most valued and often reviewed first.15 In our study, although 82% of the patients received a specialist evaluation, close to one in five charts had no definite diagnosis documented and another one in five charts documented multiple competing diagnoses without a clear indication of the working diagnosis. Disagreement between ED chart adjudication and NACRS main-position algorithm for the diagnosis of cerebral ischaemia. A common follow-up exam is for fracture care. Received 2016 Nov 21; Revised 2017 Mar 17; Accepted 2017 Apr 24. The full ED record was reviewed, including documentation from all physicians (emergentologists and consultants) and allied healthcare members who interacted with the patient. In this case, the current or primary cancer site should be coded. They cant justify medical necessity and ensure correct reimbursement when radiological findings are vague. Coders should use the observation and evaluation codes (V71.X) when no other indication is listed. Multivariable logistic regression analyses confirmed this association using different case definition algorithms. Recruitment for both studies largely took place in a tertiarycare teaching hospital with an ED volume of about 78000 visits per year, including 905 annual acute stroke consults. We did not identify any factors strongly associated with documentation of a clear final diagnosis (seeonlinesupplemental table 1). The .gov means its official. Differential includes seizures.
However, non-physician administrative data coders do not have the medical background to make such judgements. and transmitted securely. Do coder characteristics influence validity of ICD-10 hospital discharge data? SPECTRA aims to identify a blood biomarker to differentiate TIA and minor strokes from mimics and enrols patients within 24hours after symptom onset. official website and that any information you provide is encrypted The burden of risk factors was categorised as none, one risk factor, or two or more. Lack of definitive diagnosis was defined as documentation of a symptom complex, forexample, transient aphasia, resolved or weakness not yet diagnosed, or documentation of imaging findings, for example, carotid stenosis, as a diagnosis without an indication of symptomatic or asymptomatic (incidental) status. For the logistic regression analyses, charts with documented uncertainty and those without a definite diagnosis were evaluated separately because the former is unavoidable in clinical medicine and cannot be eliminated, while the latter can be acted on. ADMR contributed to the study concept and design, data interpretation, critical revision of the manuscript and supervision. Uncertainty was documented in 78 (18.7%) charts and 73 (17.5%) charts had no definitive diagnosis. The majority of disagreement (n=103/122, 84.4%) arose from adjudicated TIA cases that were misclassified as non-TIA in administrative data coding.
Complementary & Alternative Medicine (CAM), Talking to Others about Your Advanced Cancer, Coping with Your Feelings During Advanced Cancer, Emotional Support for Young People with Cancer, Young People Facing End-of-Life Care Decisions, Late Effects of Childhood Cancer Treatment, Tech Transfer & Small Business Partnerships, Frederick National Laboratory for Cancer Research, Milestones in Cancer Research and Discovery, Step 1: Application Development & Submission, National Cancer Act 50th Anniversary Commemoration, Supportive & Palliative Care Editorial Board, Levels of Evidence: Supportive & Palliative Care, Levels of Evidence: Screening & Prevention, Levels of Evidence: Integrative Therapies, U.S. Department of Health and Human Services. We also evaluated whether clinical factors were associated with differences in the content of physician documentation.
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