Good clinical documentation is critical for continuity of patient care, patient safety, legal records, and supporting accurate medical coding. The documentation provides information on why the patient was admitted and what treatments they received. The coders assign diagnosis and procedure codes based solely on the documented information. Ambiguous or incomplete documentation can result in inaccurate coding that affects funding. Ensuring documentation clearly specifies diagnoses, management plans, and interventions helps ensure patients are assigned to the appropriate Diagnosis Related Group (DRG) and the hospital receives appropriate funding for the services provided.

1. “It’s all about
the clinical
documentation!”
Delivering a Healthy WA
Sharon Linton
Area Manager Clinical Coding
North Metropolitan Health Services

2. Clinical Perspective
Good clinical documentation critical to -
• Continuity and quality of patient care
• Patient safety
– reduces errors in patient care between care givers
– leads to more timely interventions
• Legal record of a patient’s admitted episode of care
– what ‘happened to the patient’ when in our care
– forms ‘evidence’ of care provided
• Supports quality of coded data

3. Coding Perspective
Provide information on ‘why a patient is admitted and
what we do to them when here’
• Purpose to classify clinical concepts documented in
an admitted patient event
– Diagnoses/conditions that are treated/managed during the
admission
– Interventions
• Medical record is primary source of clinical
information
– Discharge Summary
– Progress Notes
– Specialty documentation/forms

4. Coding Perspective
• Not our role to ‘diagnose’
– documentation responsibility of clinicians
• Strict ‘Ethical Conduct’ standards and guidelines
– Qualify conflicting, incomplete or ambiguous
documentation
• Consult with the clinician before assigning a code
– Integrity of data
• Good quality documentation impacts on Activity
Based Funding (ABF)
“If it is not recorded, it never happened”

5. ED Documentation
Coders review everything!
• Presenting complaint information
– Might be signs and symptoms
• Verification of a ‘Principal Diagnosis’ (PD)
– Casual link between symptoms and an underlying
condition
• Management plan
– Planned interventions
– Planned investigations and/or monitoring

6. ED Documentation
• Evidence of ongoing clinical care (medical and
nursing) of condition/s
– Medical entries
• Significant/abnormal radiology and/or laboratory
results linked to condition
• Interventions
– Observation charts
– Medication charts
• Identify further specificity of PD and related
conditions
– Acute and/or chronic
– Angina – type of angina? Unstable
– ETOH / Drug Intoxication – with
abuse/dependence/withdrawal

7. Activity Based Funding
(ABF)
Basics

8. ABF Basics
• Way of funding hospitals for the number and
‘mix’ of patients they treat
• If a hospital treats more patients, it receives
more funding
• Also takes into account the fact that some
patients are more complicated to treat than
others (i.e. elderly, multi comorbidities)

9. Diagnosis Related
Groups (DRGs)
Basics

10. DRG Basics
“A classification system that categorises episodes of
patient care into clinically meaningful groups based
on the patient’s attributes that best explains the cost
of care”
• DRGs
– differing levels of resource consumption
– split on the basis of case complexity (presence of multiple
conditions or development of complications)
– each DRG has a value measured as Weighted Activity
Units (WAUs)

11. DRG Basics
AR-DRG V9.0 Description NWAU
G70A Other Digestive System Disorders, Major Complexity 1.3019
G70B Other Digestive System Disorders, Intermediate Complexity 0.6512
G70C Other Digestive System Disorders, Minor Complexity 0.2333
L64A Urinary Stones and Obstruction, Major Complexity 0.9150
L64B Urinary Stones and Obstruction, Minor Complexity 0.2503

12. ARDT Policy
Compliance

13. ARDT Policy
‘Admission, Readmission, Discharge and
Transfer (ARDT) Policy and Reference
Manual’ published by the WA DOH
• Provides rules to correctly count and classify
admitted patient activity
• Ensures standardised rules across WA health
sector
• Includes national policy and legislation from other
jurisdictions

14. ED Admission Criteria
Approved ‘inpatient’ wards in ED - EDU and OBS
Criteria for valid admission to EDU / OBS
• ‘Medical’ patients must have one of following
– Minimum of 4 hours ‘continuous active management’
• Clear care plan for ongoing management
• Document regular observations / monitoring of vital or neurological
signs undertaken on repeated and periodic basis (e.g. continuous
ECG monitoring)
Count of 4 hours from ‘clinical’ decision to admit – in EDIS, not actual
transfer time to ward

15. ED Admission Criteria
Criteria for valid admission in EDU / OBS cont.,
– Patient is a mental health patient who requires a period of safe
observation or psychiatric assessment
– Legal requirement or social circumstances necessitating
admission – unsafe for discharge
• Risk of domestic abuse
• Inadequate level of social support
• Elderly patient - home alone
• Intoxicated patient - where they are ‘left to sleep it off’
• Nursing Home patient – not able to transfer until morning
– Patients who require care awaiting transfer to another hospital –
must document ongoing care

16. ED Admission Criteria
• Patients following Type B Procedure
– Commonwealth list (Private Health Insurance Act)
• Non-admitted – Type C
• Admitted – Type B, includes where GA or intravenous/inhalation
sedation is required
– Can be less than 4 hours ‘continuous active management’
– Understand Type B procedures generally performed in ED but
transfer to EDU/OBS
• Require post-procedural observations following IV/Inhalation
sedation
• IV infusion commenced in ED and continuing in EDU/OBS

17. Documentation Quality
Impact on ABF and
DRGs

18. DRG Assignment
• Purely based on the clinical documentation
that informs the clinical coding process
• Three determinates of a DRG –
– Principal Diagnosis
– Additional Diagnoses (issues contributing to
admission)
– Surgical Interventions

19. ED Admissions
Principal Diagnosis (PD) is most important
factor in EDU/OBS inpatient events
Definition:
“The condition, which after study, is the reason for
the patient being admitted to hospital”
• NOT the presenting condition or complaint
• An incorrect PD will get wrong DRG and the
wrong WAUs!

20. Example 1
Original Documentation
Principal
Diagnosis
Abdominal pain
Additional
Diagnoses
Revenue DRG G66B
Abdominal Pain and
Mesenteric Adenitis,
Minor Complexity
WAU = 0.1999
Updated Documentation
Gastritis
DRG G70C
Other Digestive System
Disorders, Minor Complexity
WAU = 0.2333
URG Estimate*
0.0663 – 0.2425

21. Example 2
Original Documentation
Principal
Diagnosis
Chest Pain
Additional
Diagnoses
HT
Revenue DRG F74B
Chest Pain, Minor
Complexity
WAU = 0.1867
Updated Documentation
Angina, unspecified
HT
DRG F66B
Coronary Atherosclerosis,
Minor Complexity
WAU = 0.2898
URG Estimate*
0.0688 – 0.2024
Updated Documentation
Angina, Unstable
HT
DRG F72B
Unstable Angina, Minor
Complexity
WAU = 0.4355

22. Example 3
Original Documentation
Principal
Diagnosis
Syncope
Additional
Diagnoses
(Noted – KCl given)
Revenue DRG F73B
Syncope and Collapse,
Minor Complexity
WAU = 0.4423
Updated Documentation
SVT
Hypokalaemia
DRG F76B
Arrhythmia, Cardiac Arrest
and conduction Disorders,
Minor Complexity
WAU = 0.4987
URG Estimate*
0.0688 – 0.2024
* Excludes ABF Adjustments – age, indigenous
status, remote PC

23. Write it right!

24. Coding Barriers
• ‘Coding’ language’ differs from clinical
language
• Coders are not allowed to interpret -
– some forms of clinical language
– pathology or imaging results alone

25. Ambiguous Documentation
• Cannot code from summary of active issues –
– Tachycardia - Cause ? HT, CAD, Heart Failure ?
– Dyspnoea / SaO2 – ? Acute Respiratory failure
– Decreased urine output / Creatinine – ? Acute Renal
Failure
– BP - ? Hypotensive
– Positive blood cultures - ? Infection, ? Sepsis
– Falls – ? underlying cause
– Situational crisis – ? Acute Stress Reaction, ? Adjustment
Disorder
– Suicidal Ideation on background of depression – ? ‘current’
depression
– Heavy drinker – ? intoxicated, abuse/dependence,

26. Documentation Helpers
• Avoid symptoms, or presenting complaint, as the
Principal Diagnosis
• Be specific
– i.e. Stable/Unstable Angina vs unspecified Angina
• Day-to-day ‘clinical terms’
– Abbreviations with value i.e. low Hb 108
– Up/down arrows with value i.e.  plt 14
– Uncontrolled, unstable BGLs
• If no definitive diagnosis, coders can use
“Probable”, “Suspected”, “Possible”, “Likely” or
even “?”

27. Top 10 ED DRGs
DRG DRG Description
No.
Events
X62B Poisoning/Toxic Effects of Drugs & Other Substances, Minor Complexity 185
I82Z Other Sameday Treatment for Musculoskeletal Disorders 151
G70B Other Digestive System Disorders, Minor Complexity 140
X60B Injuries, Minor Complexity 134
F74B Chest Pain, Minor Complexity 132
G67B Oesophagitis and Gastroenteritis, Minor Complexity 121
B77B Headaches, Minor Complexity 115
I68B Non-surgical Spinal Disorders, Minor Complexity 96
L63B Kidney and Urinary Tract Infections, Minor Complexity 92
V60B Alcohol Intoxication & Withdrawal, Minor Complexity 85
V65Z Treatment for Alcohol Disorders, Sameday 85
Jan – Dec 2017