Abstraction and Retrieval Workflows
Key Takeaways
- Abstraction means extracting defined data elements from the record for coding, billing, quality reporting, registries, and analytics.
- Retrieval workflows require locating the correct patient, encounter, date of service, setting, and record component.
- When needed documentation is outside the current record, the coder may request patient-specific information from ancillary departments or provider offices.
- Strong abstraction is accurate, complete, source-based, timely, and consistent with facility definitions.
Abstraction and Retrieval
Abstraction is the process of pulling specific data elements from the health record and entering them into a coding, billing, registry, quality, or reporting system. The CCA exam may ask which source should be reviewed, which element should be abstracted, or what to do when needed documentation is missing.
Abstracted elements may include patient identifiers, encounter dates, admission source, discharge disposition, provider, diagnoses, procedures, present-on-admission indicators, modifiers, service units, test results, complications, and quality measure data.
Retrieval Workflow
Record retrieval starts with patient identity and encounter selection. The coder should confirm the medical record number, account number, date of service, patient name, date of birth, setting, and provider. Retrieving the wrong encounter can cause coding errors and privacy concerns.
After confirming the encounter, the coder locates the needed component. Procedure details may be in the operative report. Final diagnoses may be in the discharge summary. Medication data may be in the MAR. Outpatient medical necessity may require the order, assessment, and result.
Missing or External Documentation
Domain 3 includes requesting patient-specific documentation from ancillary departments, physician offices, or other sources. Examples include a missing pathology report, outside operative note, radiology report, consult note, or clarification of an order.
The request should be specific: identify the patient, encounter, date, missing document, and reason it is needed. It should follow facility policy and privacy rules. The coder should not use a different patient's record, a prior encounter, or a general memory of the case to fill the gap.
Abstraction Quality Checks
Good abstraction is source-based and reproducible. Another trained reviewer should be able to locate the same data element in the same record source. If a field has a facility definition, such as discharge disposition or admission source, use that definition rather than a casual interpretation.
Which statement best describes abstraction?
A coder needs pathology results to complete coding, but the report is not in the record. What is the best next step?
Before retrieving an EHR encounter for coding, which check is most important?