by Christopher G. Richards, RHIA, CCS, Senior Associate, Barry Libman, Inc.
Completeness simply refers to the problems that are created for the coder when specific pieces of documentation are missing from the medical record. This could include the missing test results. For example, the record has no x-ray reports but documentation throughout the record refers to findings in the x-ray.
Progress notes for one or more days may be missing.
Short stay summary missing (in the absence of a dictated discharge summary) with no other provider documentation.
Conversely, there may be test results, progress notes and/or summary statements that suggest the existence of specific diagnoses that are not discussed or mentioned in other parts of the record.
Missing documentation is not a physician query issue. Coders must simply address the record as incomplete and acquire the missing documentation that should be present in the record.
Documentation that exists in the record yet is unaddressed such as abnormal labs or x-rays suggestive of diagnoses that need to be discussed by a clinician before they can be coded are examples where a physician query may prove useful.
To summarize, incomplete documentation clearly needs to be assessed carefully in the context of how the unaddressed presence versus the unexplained absence of documentation affects both the coding process and the physician query process.
When incomplete documentation impacts coding process, the decision has to be made as to whether a physician query would help resolve the matter ensuring the most accurate coding possible.
- AHIMA Practice Brief: Managing an Effective Query Process, 2008
- AHIMA Practice Brief: Ensuring Legibility of Patient Records, 2003
- AHIMA Practice Brief: Guidance for Clinical Documentation Improvement Programs, 2010
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