A couple of years ago, circa 2013, when CMS (Centers for Medicare and Medicaid Services) unveiled “The 2-Midnight Rule” and the need to certify the inpatient admission, the “5 W’s for Documentation/Auditing” were born. This laid the framework for the requirements needed to certify the admission and at the same time justify the reason for the admission.
• What are we treating? Diagnosis | Procedure (if relevant)
• Where is treatment needed? Inpatient | Outpatient (Observation/Surgery)
• Why is treatment needed?
Why is this diagnosis acutely requiring attention
Relationship to chronicity
References to requiring testing, drugs, or other interventions
References in variation from baseline to current state
Potential for adverse outcome
• HoW are we treating it?
What are we actively doing requiring our level of care
Implications if not performed
• When do you think they’ll get better?
Expectation for stay
Plan for discharge
The “5 W’s” allowed providers to decipher the complexity of the certification and gave critical insight in to the needs within provider documentation (even if their EHR did not allow it so easily) to justify admission.
Fast forward to 2015, and we are in another time of rapid change and once again we are challenged with the need to adjust in the midst of smoke and frenzy. As I am one that usually doesn’t let the smoke bother me much, I started seeing once again what was needed to decipher the mystic behind documentation for ICD-10; documentation integrity.
For many years now we have been educating providers on documentation utilizing a system much more difficult than ICD-10 when it comes to making sense of a code. ICD-10 allows us the opportunity to get to the source of the code and as I experienced, puts providers at a unique advantage once they understand the “Building Blocks”.
Something most of us know is that providers, for the most part, are highly intelligent, analytical, and can meet most challenges if given the tools they need to do so. That essentially is what the “Building Blocks of Documentation” are. A foundation built with concepts of documentation with specificity being the ultimate goal.
• STATE OF THE DISEASE PROCESS
• SEVERITY OF THE DISEASE
The “Building Blocks” can be used with any diagnosis and can be utilized as a teaching tool for Coding Professionals, Clinical Documentation Integrity Specialists, and Physicians to explain the mechanics behind the code. It can be used to enhance documentation across the care continuum. What an exciting time…
By: Sharon Easterling, MHA, RHIA, CCS, CDIP, FAHIMA. CEO
Recovery Analytics, LLC