5 Pearls for a Successful Record Review
There are many ways to perform a record review with some driven by the software and facility procedures. Most record reviewers have likely developed a “routine” that fits the aforementioned drivers. This blog was created with that in mind and does not purport to reveal specifics of a record review, and instead, outlines several pearls for concepts that support a successful record review.
“The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated” (Centers for Medicare & Medicaid Services [CMS], 2020). The preceding statement has been a foundational mainstay in the introduction to the ICD-10-CM Official Guidelines for Coding and Reporting (OGCR) for many years. It is important to note there is no mention of the code assignment of the condition(s) for it is recognized by CMS that a wholistic record review is separate from code assignment. Once the thorough record review is complete, then, and only then, are codes assigned to the conditions, procedures, services and supplies/treatments.
If you are among those who feel a typographical error has been made in using the word “wholistic” instead of “holistic”, per Merriam-Webster, both are acceptable forms of the Greek root holos, meaning “whole”, even though “holistic” is the more frequently seen variation. The word “wholistic” is often used by those who wish to emphasize the entirety of something, which is the goal with this use (n.d.b).
Merriam-Webster defines context as “the interrelated conditions in which something exists or occurs” (n.d.a). The expert clinician understands that everything in the human body is interrelated – nothing occurs without an effect on another part of the body, even though it may be to varying degrees. The expert record reviewer also understands this clinical interrelationship and recognizes that documentation is the roadmap of the patient encounter.
When performing a thorough record review, context is the most critical component to ensure success. The risk of isolating a statement from the record without thoroughly reading the whole record in addition to considering the context of the statement is misinterpretation that can lead to unnecessary (and therefore, non-compliant) query development and can diminish the credibility of the reviewer.
When reviewing vital signs or diagnostic results, the adage of less is more does not apply. Identifying initial emergency department vital signs as indicators for sepsis, for example, when it is likely the patient has an elevated heart and respiratory rate from having to climb up on a cart is inappropriate without reviewing subsequent vital signs for a trend. It is crucial to identify any trends in the vital signs or diagnostic results and doing so indicates recognition that nothing is isolated in the health record. Vital sign and diagnostic result trend identification also supports the ideology of more is more.
It is difficult to look at a page in the ICD-10-CM Official Guidelines for Coding and Reporting without noting that clinical validation is stated or implied somewhere. After all, that is the basis for code assignment. The circumstances surrounding the reason for the encounter is the basis for both the principal diagnosis and the first-listed diagnosis. All other diagnoses/problems/conditions are assigned a code only when the documentation shows how the problem affected the management of the patient (Centers for Medicare & Medicaid Services [CMS], 2020).
A problem is only words unless the explanation of how it is affecting the patient’s health status is clear. Sepsis is no more serious than a paper cut without clinical validation – without complete documentation of the clinical indicators and manifestations of the problem (sepsis, for example), and without complete documentation of the planned management of the problem and subsequent patient response.
Documentation of clinical validation is a requirement that cannot be minimized, for it is critical to the health and safety of the patient.
Does the record make sense? Just as a proper sentence must contain a subject noun, a predicate verb and convey a complete thought, the health record must also convey a complete thought. The documentation must contain problems and management/evaluation in order to be a complete health record. Then, and only then, will the record support an encounter that completely and precisely represents the patient’s true health status.
A logical, complete thought is echoed in the OGCR not once, but three times when it states, “The importance of consistent, complete documentation in the medical record cannot be overemphasized” (CMS, 2020).
In summary, a wholistic record review that is viewed in a logical and contextual manner, noting both trends and clinical validation is critical to the health and safety of the patient.
Centers for Medicare & Medicaid Services. (2020). ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 – UPDATED January 1, 2021. https://www.cms.gov/files/document/2021-coding-guidelines-updated-12162020.pdf
Merriam-Webster. (n.d.a). Context. In Merriam-Webster.com dictionary. Retrieved June 14, 2021 https://www.merriam-webster.com/dictionary/context
Merriam-Webster. (n.d.b). ‘Wholistic’: A natural evolution of ‘Holistic’: The ‘w’ brings the meaning full circle. Usage notes. Retrieved June 15, 2021 https://www.merriam-webster.com/words-at-play/wholistic-word-origin-and-use