HIMagine That! Are you accurately reporting underdosing?

Donna: Sue, it has been way too long. What’ve you been up to?

Sue: I’ve been auditing a lot of ICD-10 documentation and coding post go-live.

Donna: Same here – what have you been seeing?

Sue: Well, I have to say… I see the need for improvement...

Donna: Like what?

Sue: I think there are real opportunities for organizations to do a better job reporting instances of underdosing in their patient populations.

Donna: Oh, that is definitely an opportunity organizations don’t want to miss! Accurate reporting of underdosing helps an organization explain part of their patient readmission story.

Sue: Absolutely!

Donna; What are some other examples of what you’re seeing?

Sue: Well, the other day I reviewed the chart of a patient who was admitted to the hospital in fluid overload and hypertensive urgency. The patient had end-stage renal disease due to hypertension and he missed his last two hemodialysis appointments, thus the fluid overload and hypertensive urgency. He was admitted for an urgent hemodialysis treatment and to bring his dangerously high blood pressure under control. The patient had a history of noncompliance with hemodialysis and the coding professional did assign a code for noncompliance with therapy. However, I noted in the record that the physician had documented the patient was often noncompliant with his medication and this contributed to the patient being admitted.

Donna: That is a great example of underdosing – was it coded?

Sue: No, it wasn’t coded. The physician didn’t record the specific medications for which the patient was noncompliant – the patient takes several to control his blood pressure. In this case, the coding or CDI professional should have clarified/queried the physician to find out which meds the patient didn’t take. Then they’d be able to report a code or codes for underdosing.

Donna: Interesting! I’ve noticed situations of underdosing that have been very well-documented in the record, but were not coded. I reviewed a chart of a child who was frequently admitted to the hospital with acute exacerbation of asthma. On this particular admission, it was very well documented that the child’s mom never filled the home-going prescription for an asthma medication from the previous hospitalization. The physician counseled the mom about filling the prescription this time and the social worker worked with her to ensure this was done.

Sue: That is a great example of when a code for underdosing should be used! I think coding and CDI professionals have to be on alert for these documentation clues.

Donna: I agree! The ICD-10 concept of underdosing is new and it’s going to take some time for everyone to start recognizing instances of underdosing and remembering that we now have the ability to code and report them.

Sue Belley, RHIA, and Donna Smith, RHIA, are project managers with the consulting services business of 3M Health Information Systems.