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In a recent policy brief published by the Missouri Hospital Association, analysis of neonatal abstinence syndrome and maternal opioid use data identified a possible gap in the ability to accurately identify the actual prevalence of NAS in Missouri, potentially resulting in a four-fold underestimation. The accuracy and reliability of health care data collection primarily relies on precise clinical documentation by physicians and mid-level practitioners, which is translated into International Classification of Diseases, Tenth Revision medical codes. Coded data is then translated into quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending. Strong clinical documentation and coding programs support both the revenue cycle and patient health outcomes. In the age of diverse electronic medical record systems that lack interoperability, documentation and coding capture remain challenging. This brief identifies five challenges associated with data capture of NAS and related maternal substance abuse, and provides improvement strategies for practitioners, clinical documentation integrity specialists and medical coding specialists. Reliable data will provide better understanding of this critical health care issue and help identify target areas for focused improvement.
Materials
Neonatal Abstinence Syndrome: Guidance to Improve Clinical Documentation and Data Capture
Related Topics
- Medical Care
- Clinical Tools
- Neonatal Abstinence Syndrome (NAS)