surgical H&P lacking secondary/co-morbid disease details

sbeatty

Good morning colleagues!
Our orthopedic surgery group has the habit of only addressing the orthopedic problem for which the patient is being admitted in their H&P. Once the patient is admitted, they ask the hospitalist group to manage the medical comorbiditeis, and their documentation is quite good. Unfortunately, this often creates issues with POA and CMS quality measures. Once the patient is ready for discharge, the orthopedist dictates and DC Summary that focuses again on the orthopedic surgery only. The comorbidities are generally not addressed. What have others done to work on a process to alleviate such problems between surgical admissions and medical management? All feedback, ideas, etc. gratefully accepted.
Sandy Beatty
Columbus Regional Hospital

jamiedugan2012

We have that same problem too and end up querying for additional
information. I think it is a universal issue. I do understand from
their point that if they consult medical to manage in their mind they
see no need to re-document their efforts. But, in the coding world they
are the owners of the chart and so it has to be documented by them. I
look forward to some great wisdom someone may post that would help us
all in this area.
Thanks!
Jamie Dugan RN
Clinical Documentation Improvement Specialist
Baptist Health System
Jacksonville, Florida

mdominesey

The co-morbidities do not necessarily need to be addressed by the orthopods in the D/C summary. As long as they (the co-morbidities) were addressed by the hospitalist/medical service and are not contradicted by the orthopod, then the coders can code it.

MND



Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital

Information Technology
5255 Loughboro Rd NW
Washington DC, 20016-2695

W: 202.660.6782
F: 202.537.4477


http://www.sibley.org

kshumpert

I think this is a difficult area to navigate for all entities involved. We have had some RAC denials regarding this very subject (which I appealed). My thoughts... One problem is that the surgeons do not feel comfortable documenting a condition that they are not treating and are sometimes concerned about liability associated with treatment rendered if they document the condition. Whether there is merit to their concern, I don't know.

I have discovered during documentation reviews with our physicians that some of them believe that two physicians cannot write the same diagnosis twice during an encounter; that it causes a billing snafu for one of the physicians. Perhaps the surgeons are omitting diagnoses in the discharge summary as a courtesy to the hospitalists because they erroneously believe it may cause their colleague a billing problem.

Thanks,
Kathy
Kathy Shumpert, RN, CCDS

Clinical Documentation Improvement Specialist
Howard Regional Health System
Office 765-864-8754
Cell phone 765-432-3961
Fax 765-453-8447

When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela

jamiedugan2012

Great feedback I shall ask them!

robert.hodges2

I'm wondering, and I'm trying to think why it couldn't be done, if after the surgeon dictates their discharge summary, that the hospitalist could dictate an addendum to the discharge summary for their portion of the patient care management.

Just wondering here.

Robert

Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

kshumpert

Often times that is what our hospitalists do when we have a patient that has had an extended length of stay or if it has been a complicated case. Many of our surgeons have been including a statement in their discharge summary-something to the effect "medical management per hospitalist group" and I have used the exact wording of the statement in my appeal letter and it has worked so far.

Thanks,
Kathy
Kathy Shumpert, RN, CCDS

Clinical Documentation Improvement Specialist
Howard Regional Health System
Office 765-864-8754
Cell phone 765-432-3961
Fax 765-453-8447

When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela

sharon.cole

Hi Sandra,
Our Ortho groups were doing the same thing here-consulting the hospitalist group for medical management, while ortho only addressed their area in the H&P, DC summary. Unless there was conflicting documentation (which there never was since they never addressed anything), the secondary diagnoses were coded if there was supporting documentation/treatment. We recently started getting ADRs for DRG 470. The hospital AND the ortho groups were being denied. They were all overturned on appeal but it's still such a hassle. We had a meeting with one of the ortho groups, I created a "cheat sheet" to remind them of what they needed to document/address in the H&Ps and DC summaries so these cases would not be denied. I also explained why it was important for them to address secondary diagnoses. They still don't pick up every secondary diagnosis, but they are getting a little better.

I had a documentation education session with each of our CV surgeons too and 2 of the 3 will at least now say they "concur with nephrology's diagnosis of acute kidney injury (or whatever the specialist's write)". It's not the best but at least they are now thinking about it.

Last Christmas when Melissa sent out requests for our CDI wish list, mine was to have 30 minutes with each physician - and since that time, I have met with the largest OB/Gyn grp, the CV surgeons, the largest ortho grp, and the Medical director of the Hospitalist grp. It's been absolutely wonderful for our documentation! I asked our HIM director to accompany me so I had coding expertise.

Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
srcole@phn-waco.org