Discharge summaries
Good morning, everyone!
I am looking for some feedback re: Discharge summaries.
We are repeatedly being notified by our coders to retrospectively query our physicians for diagnoses that are not being included in the discharge summary.
For example, a patient was admitted with diagnoses of sepsis and pneumonia. On the discharge summary, the physician lists the final diagnosis as pneumonia. Sepsis is written throughout the medical record for 3 days but is not carried over to the discharge summary. We are then asked to retrospectively query the physician for an addendum to the DS to include the diagnosis of sepsis before that diagnosis will be coded.
This has also started to occur with patients that may have only 1 cc/mcc during their stay and the physician does not include that cc/mcc in the DS.
When asked why these dx are not being coded, we are told that since this dx was not in the DS, it appears that it was ruled out and thus not be coded. The RAC is often mentioned but no one has been able to confirm or site examples where payment was denied b/c a diagnosis was coded and not found in the discharge summary.
Is there anyone that can help us with this? Thanks
I am looking for some feedback re: Discharge summaries.
We are repeatedly being notified by our coders to retrospectively query our physicians for diagnoses that are not being included in the discharge summary.
For example, a patient was admitted with diagnoses of sepsis and pneumonia. On the discharge summary, the physician lists the final diagnosis as pneumonia. Sepsis is written throughout the medical record for 3 days but is not carried over to the discharge summary. We are then asked to retrospectively query the physician for an addendum to the DS to include the diagnosis of sepsis before that diagnosis will be coded.
This has also started to occur with patients that may have only 1 cc/mcc during their stay and the physician does not include that cc/mcc in the DS.
When asked why these dx are not being coded, we are told that since this dx was not in the DS, it appears that it was ruled out and thus not be coded. The RAC is often mentioned but no one has been able to confirm or site examples where payment was denied b/c a diagnosis was coded and not found in the discharge summary.
Is there anyone that can help us with this? Thanks