FW: Discharge summaries
Assuming the condition was ruled out just because it was not in the discharge summary-Um, NOT best practice!! Coders are not allowed to make assumptions; a query was warranted in those cases. (Followed up with MD education)
I write appeals as well, so I do like for the Pdx, cc/mcc's, and Pcx to be in the discharge summary. The case "appears" to be more solid in the eyes of an auditor. I would ask for the MD to addendum the discharge summary. If/When the patient is readmitted, the discharge summary may likely be the only document referenced from the previous stay. Leaving conditions out of the discharge summary may result in treatment delays or other unfavorable outcomes.
Good luck!-V
Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com
“If your actions inspire others to dream more, learn more, do more and become more, you are a leader.” - President John Quincy Adams
“Therefore encourage one another, and let each one help to strengthen his friend, as in fact you do” 1Thessalonians 5:11
I write appeals as well, so I do like for the Pdx, cc/mcc's, and Pcx to be in the discharge summary. The case "appears" to be more solid in the eyes of an auditor. I would ask for the MD to addendum the discharge summary. If/When the patient is readmitted, the discharge summary may likely be the only document referenced from the previous stay. Leaving conditions out of the discharge summary may result in treatment delays or other unfavorable outcomes.
Good luck!-V
Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com
“If your actions inspire others to dream more, learn more, do more and become more, you are a leader.” - President John Quincy Adams
“Therefore encourage one another, and let each one help to strengthen his friend, as in fact you do” 1Thessalonians 5:11