Medical Record Guidance

We often get questions about what constitutes a complete medical record.  To date, there is no all-encompassing official definition, although CMS provides their requirements during a Risk Adjustment Data Validation.

For offices, groups and health plans trying to develop coding compliance policies, there hasn't been a lot of information available.  Recently, the American Health Information Management Association (AHIMA) has tackled the issue head on in Defining the Core Clinical Documentation Set for Coding Compliance.  This useful article will help anyone tasked with creating a coding compliance policy.  You can find a copy of this paper here.

Coding versus Interpreting

As coders, we're required to code based upon the physician's documentation, and not to read into what the physician has actually written. 

Recently, we received the following question and follow up questions in the Coding@scanhealthplan.com inbox. 

Original Question: 

I would like to know some opinions regarding to coding the following documentation by Physician:  “ Vascular Dementia”.   

Our Answer: 

Vascular dementia NOS is indexed to 290.40.  I don’t see any alternative code.

Then, we received a follow up:

Follow up Question: 

In my opinion I’ll use 290.40 plus 437.0.   Please see instructional notes “ Use additional code to identify cerebral atherosclerosis”.  I need your opinion.

Our Answer:

You only use an additional code if it’s documented. It’s not something you automatically do.  Based on your email, the physician only documented vascular dementia.  If he had said vascular dementia due to cerebral atherosclerosis, then you would code it.

 The instructional notes for 250.40 say:

Use additional code, to identify manifestation, as: 
        chronic kidney disease  (585.1-585.9) 
             diabetic: 
             nephropathy NOS  (583.81) 
             nephrosis  (581.81) 
             intercapillary glomerulosclerosis  (581.81) 
             Kimmelstiel-Wilson syndrome  (581.81) 
 But you don’t code all those things unless they are documented.
I hope that clarifies.

In response, the questioner indicated that they planned on coding cerebral atherosclerosis  (437.0) because:

"Vascular dementia, Arteriosclerotic Dementia, Multi-infarct Dementia and Atherosclerotic disease are synonyms.   In my opinion the documentation of Vascular Dementia is the same as  Atherosclerotic Dementia or multi-infarct Dementia.    

Please look Dementia
                                       Multi-infarct(cerebrovascular) ( see also Dementia, arteriosclerotic)"

 
I don't believe I did a good enough job explaining why you wouldn't code something not documented.  But the reality is that cerebral arteriosclerosis is not the only cause of vascular dementia, although it may be the most common cause.  Multi-infarct dementia (MID), due to multiple strokes or TIAs,  or mixed type due to MID and Alzheimers, or many other

 conditions that reduce blood flow to the brain, including certain autoimmune diseases (e.g., lupus eythematosus, temporal arteritis), certain inherited (genetic) diseases, infections of the heart (endocarditis), brain hemorrhage, profoundly low blood pressure can also cause vascular .   Since arteriosclerosis is not the sole cause, coding 437.0 without documentation of cerebral arteriosclerosis is not appropriate.  As coders, we must code what's documented, without inserting our knowledge of disease states or opinions into the process.