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  
0 Votes - Sign in to vote or comment.

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.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

​​Polysomnography Services Under OIG Scrutiny
September 2nd, 2021 - Raquel Shumway
The OIG conducted a study dated June 2019 wherein they indicated that there were approximately $269 million in overpayments for polysomnography services for the period of 2014 through 2015. According to the OIG “These errors occurred because the CMS oversight of polysomnography services was insufficient to ensure that providers complied with Medicare requirements and to prevent payment of claims that didn’t meet those requirements.” So what are those requirements?
Medicare Advantage - The Fastest Growing Government-Funded Program Undergoing Multiple Fraud Investigations
August 16th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Medicare Advantage is the fastest growing form of government-funded healthcare and the rate of fraud within this segment has come under increased scrutiny. Funding is determined by the health status of each beneficiary; therefore, accurate coding based on detailed documentation makes the medical record vital to the process because some ...
Billing Dental Implants under Medical Coverage
August 12th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Implants can be costly to the patient and the provider, and it is crucial to understand how to bill a patient’s medical insurance to ensure there is adequate coverage for the best treatment. Implants are commonly billed in a dental office under a patient’s medical benefits.    Implants could be considered ...
New Codes for COVID Booster Vaccine & Monoclonal Antibody Products
August 10th, 2021 - Wyn Staheli, Director of Research
New codes have been announced for the COVID-19 booster vaccine, Novavax vaccine, and monoclonal antibody treatment.
Medicare's ABN Booklet Revised
July 29th, 2021 - Wyn Staheli, Director of Research
The “Medicare Advance Written Notices of Non-coverage” booklet, published by CMS’s Medicare Learning Network, was updated. This article discusses the changes to this booklet regarding the use of the ABN.
Chronic Pain Coding Today & in the Future
July 19th, 2021 - Wyn Staheli, Director of Research
Properly documenting and coding chronic pain can be challenging. As is commonly the case with many conditions, over the years, there has been a shift in the identification of different types of pain, including chronic pain. Understanding where we are now and where we are going will help your organization prepare for the future by changing documentation patterns now.
How Does Global and Professional Direct Contracting (GPDC) Affect Risk Adjustment?
July 15th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
CMS recently announced the 53 Direct Contracting Entities (DCEs) that will be participating in the April 1, 2021 through December 31, 2021 Global and Professional Direct Contracting (GPDC) Model. Among those participating is Clover Health Partners, who runs an in-home primary care program that has the potential to help Medicare ...



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2021 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association