discharge summaries
Is anyone else running into issues with discharge summaries? We have several physician groups who contract with an independent nurse contractor and her employees to dictate their discharge summaries. Recently, some of the private payors have denied the PDX because, even though it may be written in the H&P and every single PN, it is not included in the DC summary.
We have provided education to both the physicians and this group of nurses but the issue continues to be an ongoing challenge. Like many facilities, we don't always have the DC summary before the chart is coded.
Our current process is to query the physician/nurse if the DC summary is on the chart prior to coding and it doesn't match the rest of the record. We add a DC summary addendum with the correction.
Are there any facilities where your CDI program has taken over the dictation of the DC summaries to make sure the diagnoses accurately reflect the rest of the record?
Thanks!
Julie Doy
We have provided education to both the physicians and this group of nurses but the issue continues to be an ongoing challenge. Like many facilities, we don't always have the DC summary before the chart is coded.
Our current process is to query the physician/nurse if the DC summary is on the chart prior to coding and it doesn't match the rest of the record. We add a DC summary addendum with the correction.
Are there any facilities where your CDI program has taken over the dictation of the DC summaries to make sure the diagnoses accurately reflect the rest of the record?
Thanks!
Julie Doy
Comments
To begin with, I hope you are appealing the denials. If the diagnosis is
fully supported throughout the record, it does not have to be in the DC
summary. I have heard software is being created that will allow CDS's to
populate a discharge summary throughout the stay, therefore having a
complete DC summary at the end. We have not tried this yet. I was made
aware of it from our JaThomas consultant, something they are/have created.
Thank You,
Susan Tiffany RN, CCDS
Supervisor Clinical Documentation Program
Guthrie Healthcare System
phone: 570-882-6094, pager #465
fax: 570-882-6768
email: tiffany_susan@guthrie.org
"Twenty years from now you will be more disappointed by the things you
didn't do than by the ones you did do. So throw off the bowlines. Sail
away from safe harbor.Catch the trade winds in your sails. Explore. Dream.
Discover." Mark Twain
Something I believe I will want to explore further.
As long as the diagnosis is described in language that clearly confirms (not probable / possible), I agree, it should not be required in the DCS. BUT.....as a relevant and active diagnosis it SHOULD be in the DCS. I would definitely also considering appealing.
Don
If we could only take what's in the discharge summary, we might as well sit on our hands until the patient leaves and just do retrospective reviews. Or burn the H/P and progress notes, since they clearly are irrelevant...right?
Our coders will assign a chart to the "waiting for discharge summary" queue in the system, and then re-review when the discharge summary is dictated, to make sure there are no significant discrepancies.
Renee
Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital
Tracy M Peyton RN, CCDS
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406
Thanks,
Kathy
Kathy Shumpert, RN, CCDS
Interim Director Outcomes Management
Clinical Documentation Improvement Specialist
Community Howard Regional Health
3500 S Lafountain
PO Box 9011
Kokomo, IN 46904
Office 765-864-8754
Cell phone 765-431-0123
Fax 765-453-8447
When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela
Sharon Cole, RN, CCDS
CDI Specialist Team Leader
Providence Health Center
254.751.4256
Sharon.cole@phn-waco.org
Linda Haynes, RHIT, CCDS | Manager, Clinical Documentation Improvement | Legacy Health
1919 NW Lovejoy | Portland, Oregon 97209 | 503-415-5609 | lhaynes@lhs.org
The basic rule for coding a confirmed diagnosis that is documented any where in the chart is stated in the guideline illustrated below: “When the documentation in the medical record is clear and consistent, coders may assign and report codes.” Therefore, it matters not whether the diagnosis is ‘repeated’ or ‘mentioned’ in the discharge summary, and this is why, in general, charts are coded, dropped, and billed, even if the discharge summary is not yet dictated or transcribed.
There was a screen shot but it seems Lyris will not let me add.
Donna
Donna Kent, RN, BSN, CCDS
Manager, Clinical Documentation Integrity Program
Clinical Quality and Accreditation
Torrance Memorial Medical Center
ph.:310 784-6884 fax:310 784-6899
donna.kent@tmmc.com
Donna Kent, RN, BSN, CCDS
Manager, Clinical Documentation Integrity Program
Clinical Quality and Accreditation
Torrance Memorial Medical Center
ph.:310 784-6884 fax:310 784-6899
donna.kent@tmmc.com
Thank you so much for your input. We, too, have been told that there have been RAC denials b/c of exclusion of dx from the DC summary. Currently, there is not a CDI that participates in RAC reviews; however, the idea has be mentioned.
Val Miller BSN,RN,CCDS
Georgetown Hospital System
Waccamaw Community Hospital
Murrells Inlet, SC
Val Miller BSN,RN,CCDS
Georgetown Hospital System
Waccamaw Community Hospital
Murrells Inlet,SC
Deanne Wilk, BSN, RN, CCDS, CCS
AHIMA approved ICD-10-CM/PCS Trainer
Clinical Documentation Improvement and Inpatient Coding Manager
HIMS Department
Good Samaritan Health System
4th & Walnut Sts
Lebanon, PA 17042
dwilk@gshleb.org
Phone: 717-270-7582
Cell: 717-580-1436