Audit exercise: find the errors

Find the errors

Two records have been coded. Your job is to find what is wrong, then check the fix.

What the clinician wrote

Record A. The clinician documented a hip fracture from a fall as the main condition, and severe hypothermia from exposure to cold weather as another condition. Pause, and decide how you would code it.

• Main condition · Hip fracture · From a fall.
• Other condition · Hypothermia · Severe, from exposure to cold weather.

Three errors

As submitted: hypothermia was chosen as the main condition. The fracture was coded, but the fall was reported alone, not linked to it. And the hypothermia has no external cause.

• Main condition · NF02 · Hypothermia was chosen as the main condition.
• The fracture · NC72.2Z · Coded, but the fall was reported alone, not linked to it.
• Hypothermia · No cause · Its external cause was left out.

Fracture first, each with its cause

The fix. The hip fracture is the main condition the practitioner identified. It is linked to its fall. The hypothermia is another condition, linked to its own external cause.

What the clinician wrote

Record B. The main condition is rheumatoid arthritis. The other conditions are hypertension, type 2 diabetes mellitus and cataract. The cataract is not described as diabetic.

• Main condition · Rheumatoid arthritis · Serology unspecified.
• Other conditions · Three · Hypertension, type 2 diabetes mellitus and cataract.

One error

As submitted, the cataract and the diabetes were linked in one cluster. That is wrong. No causal relationship is documented, so the two stem codes cannot be part of the same cluster.

• The cluster · 9B10.Z/5A11 · The cataract was linked to the diabetes in one cluster.
• Why it is wrong · Not documented · No documented causal relationship, so they cannot be part of the same cluster.

Four codes, no cluster

The fix. Rheumatoid arthritis is the main condition. Hypertension, type 2 diabetes and cataract are coded separately, with no cluster linking them.

Keep these in mind

Check the main condition against the reason for admission. Every external cause is linked to its own condition. And never cluster what is not documented as linked.

• Check the main condition against the reason for admission
• Every external cause is linked to its own condition
• Never cluster what is not documented as linked