The “Building Blocks of Documentation”: Cornerstone I: State of Disease

As providers venture into the world of new payment models and methodologies, having the tools to do that seamlessly and knowledgably is critical for success. Understanding and implementing the “Building Blocks of Documentation” can be a crucial first step in facing and succeeding at that change.

Essentially the “Building Blocks of Documentation” are a foundation built utilizing concepts of documentation with specificity being the ultimate goal. Within the Building Blocks are 4 concepts: State of Disease, Severity of Disease, Etiology/Type, and Laterality. It is important to keep in mind, it is sometimes only possible to document to the extent of the information available. Documentation should always be taken seriously and conditions should only be documented to the extent the provider has the ability to. Also remember, documentation versus coding is two distinct processes and coding rules and guidelines also drive the assignment of a code. Documentation is needed far beyond code assignment such as with medical necessity to support services performed, level of care, and justification of treatment. Therefore, providers should document for the patient, for the services performed, and for quality, to yield accurate reimbursement.

With leading into this Cornerstone, the question of “Why talk about acuity and chronicity?” most likely comes to mind. As the discussion of documentation is entered into, bringing attention to this is important as it is oftentimes overlooked when documenting. As a provider, the acuity of the patient should be clear as the patient is newly presenting to the hospital or clinic for treatment. The real fact of the matter is ACUITY and CHRONICITY ARE NOT ALWAYS CLEAR IN THE CURRENT STATE OF THE DISEASE AND MANY TIMES IS NOT DOCUMENTED. This has to be evident through clinical indicators, treatment, and also documentation. A great example of this is:

• A patient may have the chronic condition of asthma but if that patient presents with wheezing and shortness of breath it is most likely an acute exacerbation of the patient’s chronic asthma.
• If a patient has chronic CHF and presents with short of breath, pedal edema, and not taking their Lasix for days, it is most likely acute on chronic CHF.
• Chronic conditions can become acute conditions in many forms if left untreated or due to the nature of the disease; for example, fractures in osteoporosis.

A chronic condition can have acute episodes; exacerbations or decompensations, of the illness. This is at times seen stated as acute on chronic. Clinical indicators and treatment can lead to conclusions but the documentation has to be within the record for code assignment and to justify medical necessity. This area remains a significant challenge within clinical documentation programs. Taking a look at why the problem persists gets providers a step closer to solving it. Knowing the “Building Blocks” is a significant first step.


Upcoming webinar:  Webinar: “Building Blocks of Documentation”: Cornerstone I – State of Disease

Contact Recovery Analytics, LLC to learn more about the “Building Blocks of Documentation”.

By: Sharon Easterling, MHA, RHIA, CCS, CDIP, FAHIMA
Recovery Analytics, LLC

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