Documentation and coding for trauma and surgical critical care: updates and tips

Abstract

Clinical documentation is an essential part of medical practice. Medical records serve as a durable testament of care provided and are fundamental to communication among providers. Medical records provide justification and support for healthcare coding and billing for providers and hospitals and also provide evidence in regulatory and legal proceedings. Here, the authors emphasize the importance of clinical documentation in support of both professional and hospital billing and address two areas of recent regulatory changes: Operative coding for hernia operation and professional coding for critical care. The important role of provider documentation in supporting organizational revenue and quality is also discussed.

Keywords: Health Care Economics And Organizations; critical care; documentation.

Figure 1. Documenting complications and comorbidities changes the DRG weight. Common acute and chronic medical diagnoses may constitute CC’s or MCC’s. If documented accurately, CC’s and MCC’s increase the base MS-DRG weight. CC, complication and comorbidity; MCC, major complication or comorbidity; MS-DRG, Medicare Service-Diagnosis Related Group.

Figure 2. . Example of effect of accurate documentation of MCC’s on MS-DRG weight. Patients with acute and chronic physiologic abnormalities like acute hypoxic respiratory failure and hemorrhagic shock are more complex and demand more healthcare resources. Accurately documented CC’s and MCC’s assures healthcare organizations gain the revenue necessary to provide care. CC, complication and comorbidity; MCC, major complication or comorbidity; MS-DRG, Medicare Service-Diagnosis Related Group; OR, operating room.