Holistic coding requires amped up clinical documentation.

摘要

ACCURATELY CODED DATA does more than just provide the mechanism for appropriate reimbursement. It also tells the story of the patient, the complexity of the patient's case, and reflects the care provided to the patient. This growing trend of "holistic coding" seems to be gaining attention in the healthcare industry. Holistic coding in the inpatient setting goes far beyond the basic capture of the MS-DRG. To apply classification codes with a holistic approach means identifying not only the MS-DRG and principal and secondary diagnoses and procedures, but the additional elements that come from a full clinical documentation improvement review as well. Other elements sought out by coders and clinical documentation integrity specialists contribute to achieving the goal of holistic, accurately coded data.