ST.

ANTHONYS MEMORIAL HOSPITAL/EFFINGHAM, IL

Author: Kristy Hurst 9April2014
POSITION: CLINICAL DOCUMENTATION SPECIALIST (CDS)
DEPARTMENT: HEALTH INFORMATION MANAGEMENT
REPORTS TO: HEALTH INFORMATION DIRECTOR
CLASSIFICATION: NON-EXEMPT
SCHEDULE: 6:30AM-3PM MONDAY-FRIDAY

POSITION SUMMARY:
The CDS reviews medical records to ensure the accurate DRG is billed by improving the quality
of the physicians documentation. Interaction daily with physicians, coders, and nursing staff is
required. Participation in team meetings and the morbidity council as well as educating staff on
the Clinical Documentation Management Program process are important aspects of this role.
DUTIES:
Reviews new admission and continued stay Medicare patients to formulate and update a
working DRG.
Creates queries for physicians to clarify documentation and obtain missing
documentation and/or reports. Follow-up as needed to resolve open issues.
Working with staff to increase the quality of documentation in order to accurately reflect
the severity of illness and risk of mortality.
Completes CDMP documentation in the software system for all cases reviewed.
Attends and actively participates in meetings as required for CDS.
Works with JATA consultants on assessing program and making improvements.
Works with hospital physician liaisons on any Medical staff compliance concerns.
EDUCATION:
Nursing (BSN preferred) or Health Information Management graduate
CERTIFICATION, REGISTRATION, LICENSURE:
Registered Nurse, Certified Coding Specialist, Registered Health Information Administrator or
Registered Health Information Technician
SKILLS:
Basic software applications, email application and electronic medical record system experience
Organized, analytical, independent, dependable and problem solving skills
Ability to stand for long periods of time and push/pull a cart with laptop and supplies
ST. ANTHONYS MEMORIAL HOSPITAL/EFFINGHAM, IL

Author: Kristy Hurst 9April2014


EXPERIENCE:
Strong medical/surgical or intensive care experience or similar experience in coding or
documentation improvement program






















ST. ANTHONYS MEMORIAL HOSPITAL/EFFINGHAM, IL

Author: Kristy Hurst 9April2014


Process Chart






Scheduled service, test,
or surgery
Register (HIM receiving
EMR documents)
Service, test or surgery
(HIM receiving EMR
documents)
Discharge/Leave (HIM
receiving EMR
documents)
Paper portion of
outpatient record
delivered to HIM
immediately...inpatient,
observation, same day
service delivered next
morning
Prepping paper record
Scan paper record into
EMR
Quality check of record &
paper record to file
storage room for
retention of 30 days
Record analysis
Physicians &
departments are sent
Meditech notices for
deficiencies.
Record completion
ST. ANTHONYS MEMORIAL HOSPITAL/EFFINGHAM, IL

Author: Kristy Hurst 9April2014





Release of Information to the Coroner

PURPOSE:

To establish criteria and processes for releasing information to the Coroner that is compliant
with Illinois Law and HIPAA.

DEFINITION:

All deaths must be reported to the Coroner.

NARRATIVE:

Telephone reporting of expired patients will be performed by nursing colleagues in the
department where the patient expired. The reporting nurse will provide the coroner with the
following information:
-Patient Name -Admission Reason
-Date of Birth - Length of stay
-Time of Arrival -If patient coded or do not resuscitate
-Fax with History & Physical report and Body Disposition form

Administrative Guideline: Release of Information to Coroner
Section:
Effective Date: May 2014
Revised:
Origin: Health Information (TP)

ST. ANTHONYS MEMORIAL HOSPITAL/EFFINGHAM, IL

Author: Kristy Hurst 9April2014
Coroner requests for copies of medical records during HIM business hours will be managed by
HIM colleagues. Requests during other hours will be managed by the Nursing/House
Supervisor. All requests must be documented on a request form from the coroner, on the fax
cover sheet sent, or a release of authorization form the coroner signed specifically listing what
was released, when released and the manner (fax, paper copies to coroner, etc.). Release of
information via phone is discouraged, but will be allowed for emergency needs. Phone release
of protected health information will be documented the same as faxed, electronic and paper
release.

Patient expired in hospital:
Will release any records for expired patient requested by Coroner with the exception of mental
health counselor documentation. Coroner will be instructed to get a Court Order from a judge
or contact the mental health provider for copies.

Patient expired outside of hospital:
Will release any records for expired patient requested by the Coroner from the past 30 days
with the same exception for mental health counselor documentation as noted above. For
records prior to this time period the Coroner will document the specific need for these older
records. If a specific need for the records is established the records will be released. If a need
for the records cannot be established the hospital will require a court order from a judge for
the release of information.

Request for Demographic Information Only:
If medical records are not requested and the coroner is requesting social security number, next
of kin contact information or other demographic information to assist with the initial
investigation the information can be released via phone. It must be documented the same as
any other medical record request.





ST. ANTHONYS MEMORIAL HOSPITAL/EFFINGHAM, IL

Author: Kristy Hurst 9April2014
APPROVED: ___________________________


DATE: ___________________________


REFERENCE:



















ST. ANTHONYS MEMORIAL HOSPITAL/EFFINGHAM, IL

Author: Kristy Hurst 9April2014





Outpatient Coding Guidelines

PURPOSE:

To establish guidelines for properly coding outpatient records in order to receive appropriate
payment and accurately reflect level of service provided.

GUIDELINES:
Coders follow the Standards of Ethical Coding developed by AHIMA
Chart Lacks Sufficient Information to Code the Diagnosis/Indication-Complete a
Physician Query for Outpatient Tests form and fax it to the physician. Once the physician
completes and returns the query form, it becomes a permanent part of the record.
Examples: the only diagnosis documented is ruled out; possible, probable, questionable,
suspected, most likely, suggests, borderline, or suspicious or where no diagnosis or
indication is documented.
Tests-Verify all tests have been received. Inform the HIM Associates to query the
appropriate department for missing tests. Additionally, all tests require a signed order
with indications. The diagnosis must come from the ordering physicians order with the
exception of pre-employment drug screens and screening mammograms. If an order is
not on the chart, the department (lab, imaging, dietary, etc.) is notified and is
responsible in getting an order. If a diagnosis is not on the order, follow the directive in
Chart Lacks Sufficient Information
Lab-Abnormal findings will not be coded. The coder will only code the reason the lab
test was performed regardless of the results.
Imaging/Diagnostic Services-Code the reason the imaging/diagnostic service was
performed unless the radiologist/physician interprets it to show a definitive diagnosis or
an abnormal finding. In this case, the radiologist/physicians interpretation should be
coded rather than the sign or symptom given by the ordering physician. If a fracture is
Administrative Guideline: Outpatient Coding
Section:
Effective Date: April 2014
Revised:
Origin: Health Information (KH)

ST. ANTHONYS MEMORIAL HOSPITAL/EFFINGHAM, IL

Author: Kristy Hurst 9April2014
diagnosed, it will be coded as primary. Otherwise, it is not necessary to code the
interpretation.
ER-Code from the ER physicians documentation. If lab was ordered, abnormal results
will not be coded unless documented by the ER physician. If imaging/diagnostic services
were ordered, the radiologist/physicians interpretation can be coded.
ER Level of Service-Assign through Lynx. Select symptoms, problems, nursing
assessments (from nursing documentation) and chronic care notes. Up to 6 nursing
assessments and/or chronic care notes can be selected. If patient has critical care given
the coder will email the ED charge nurse to decide whether critical care time supports
documentation and will provide the length of critical care times. Select any Lab, X-rays,
EKG, CT, MRI/Ultrasound completed. Mode of arrival and disposition are also
selected. Consults with social/ancillary service or Psych/Social crisis will also be
selected. Charge infusions and injections. Adjust the level of service or do a no
charge based on certain criteria such as LWBS.
Mammogram-Code diagnostic mammograms as any other order. Screening
mammograms do not need a physician order or diagnosis. Use V76.12 for screening
mammograms without any risks. Use V76.11 for screening mammograms for high risk
patients if documented risks: 1-Prior diagnosis of breast cancer; 2-history of biopsy or
lumpectomy; 3-history of family diagnosis of breast cancer. List risk codes along with the
screening code. Include code 793.80 other findings on radiological examination of
breast if findings determine further study is needed. Fitting for Mastectomy bras need
an order with one of these 3 codes listed: V45.71, V10.3, 174.9.
Admit Diagnosis-Code on Medicare accounts when the final diagnoses do not show the
medical necessity to support the tests/services performed.
Procedures-Codes for injections, infusions, immunizations, and vaccinations will be
coded.
Same Day Medicare Accounts-When a Medicare patient has two separate outpatient
accounts with the same day of service, the charges are automatically combined for
billing but the medical records and abstracting system will maintain separate accounts.
Diagnosis codes (as opposed to descriptions) on outpatient orders from physician offices
can be coded on outpatient claims.
Change requests-If a patient, physician, or other involved party requests a change in the
diagnoses, indications, or codes, the physician must submit a signed and dated
statement with the appropriate diagnosis before the account will be re-billed with the
corrected or additional diagnoses.
Prairie Heart Institute (Effingham, Springfield, Olney, Flora locations)-Code consult
only as V65.8 Other reasons for seeking consultation for both adult and pediatric
consultation. Device check for cardiac monitor should be coded V53.39 Fitting and
adjustment of other cardiac device. Code V58.89 Other specified procedures and
aftercare plus V58.73 Aftercare following surgery of the circulatory system, not
elsewhere classified. These codes are to be used for follow-up of heart catheter
procedure for blood pressure and incision check code.
ST. ANTHONYS MEMORIAL HOSPITAL/EFFINGHAM, IL

Author: Kristy Hurst 9April2014
Physical Therapy-Accounts with EI (Early intervention), as reason when patient age
ranges from infant to young child, do not have an order or charges. Code only V57.1
'Other physical therapy'.
Disability Clinic Accounts-Do not code as per written by physician. Rather when this
stamp is on the order, code: V68.01 "Disability Examination" plus one or more of the
following codes depending upon services provided:
o V72.5 Radiology exam, NEC
o V72.60 Laboratory examination, unspecified
o V72.19 Other examination of Ears and Hearing
o V72.85 Other specified examination


TIPS:

Lab-Coding Clinic First Quarter 2000: The laboratory (independent or hospital-based) should
code the symptoms, because no physician has interpreted the results.

ER-As of date of service 1 April 2000, a presenting diagnosis will be coded on all ER visits.

Mammogram-BC/BS Guideline: Always list other screening mammogram code, V76.12 and if
documented, add codes for high risk patient with specific code defining risk.


APPROVED: ___________________________

DATE: ___________________________


REFERENCE:
ST. ANTHONYS MEMORIAL HOSPITAL/EFFINGHAM, IL

Author: Kristy Hurst 9April2014