Acronyms and Abbreviations: When You Fall into the Grey Area

October 6th, 2017 - Omega Renne, CPC, CPMA, CPCO, CEMC, CIMC
Categories:   Documentation Guidelines   Electronic Medical Records (EMR/EHR)   Medical Records  
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We've all been there... you are coding or auditing, and then a note comes up that is not like the ones you've reviewed before. The language is unclear, the acronym(s) could mean so many different things, and it's hard to get a straight answer about whether or not it's supported higher or lower. This is the grey area: where things that can mean many things, or nothing at all, and is the deciding factor for whether the encounter is supported.

Acronyms

My favorite example of an acronym grey area is "PE". PE can mean pleural effusion, pulmonary embolism, physical exam, pigmented epithelium, etc. There are more than 60 medical examination terms that are abbreviated as "PE". Sometimes it is clear when you read into the context of the note.

If a provider is doing a skin exam, then PE is probably not referencing the lungs. However, if the provider is a pulmonologist, using PE could be hard to clarify since both pulmonary embolism and pleural effusion are both affecting the lungs. In this instance, asking the provider what they meant may not be enough.

When the record could mean too many things, a statement of clarification should be added to the record. If an outside auditor were to review the record and cannot determine what it is, then the record may end up being compromised. Many practices have developed a list of approved acronyms that remain on file, and when a practitioner uses one that is not on the list it can be added to the list, or the provider may need to add a statement of clarification to the record.

Abbreviations

When it comes to abbreviations, there are some that are very commonly mixed up or misinterpreted. Although it was most prevalent in written notes, it is still a concern in the age of electronic health records. IJ is a good example as it is commonly mistaken as IV (intravenous) or IJ (intrajugular), when it is supposed to be the abbreviation of injection. Depending on fonts, it may even be mistaken as U which is the abbreviation for units.

Although this may seem like it should be obvious in the context of the encounter, these abbreviations are still causing concerns in hospitals, pharmacies and clinics due to the risk it presents to the care of the patient. Determining what was meant when it is not clear may depend largely on the policies within your practice. If it is something that you can determine based on common abbreviations/acronyms and the context of the note, a simple verbal or email clarification would be sufficient. However, if it is possible that more than a few options would be relevant given specialty and context, it would be a best practice to request clarification be added into the record.

As coders and auditors, you get to know your providers and their language very well. When these situations come up, it is important to understand when to reach out and how to proceed from there. If you can support multiple options, or cannot understand what was intended, it probably needs to be clarified.

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