Possible/probable dx

katysuegood@gmail.com

Hi All,
I was recently made aware of a denial we received on a patient with a minor SAH (3 day LOS). It was coded with one CC of ‘possible’ hyprocephalus. The hydrocephalus was documented by neurosurgeon and the attending but is NOT in the d/c summery. A definitive dx was not made, it is always stated as ‘possible’. The insurer has denied the claim stating that all ‘possible/probable’ dx must be included in the d/c summery in order for them to be coded.

Thoughts?

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

evanspx@sutterhealth.org

3rd parties are fond of stating "all diagnoses must be documented in the Narrative (D/C) Summary in order to be coded', which is not a valid statement as there are a multitude of Coding Clinics stating o/w.

However, what should be considered is the rule below from the Official Guidelines regarding the coding of 'possible' conditions. (Was the statement documented 'at the time of discharge in a progress note, for instance)?


"If the diagnosis documented AT THE TIME OF DISCHARGE is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. Note: This guideline is applicable only to short-term, acute, longterm care and psychiatric hospitals."

Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.637.9002
Fax:  415.600.1325
Ofc:  415.600.3739
evanspx@sutterhealth.org

katysuegood@gmail.com

Paul,
Yes, I believe they are quoting that guideline. The dx was in the consult and the progress notes up to d/c but NOT listed in the discharge summery.

Thanks!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

evanspx@sutterhealth.org

In that case, I disagree with them for a multitude of reasons - prime reason, the probable condition WAS documented by an MD at the time of D/C - perhaps not in the formal summary, but at the time of D/C.

Ergo, what is their logic to deny? Do we need hypertension, COPD, DM to be listed in a D/C Summary? (No - of course not).

If the hydrocephalus qualified per UHDDS Definition of a Reportable Condition, I would contest and I would ask them to state any requirement that any/all conditions coded must appear in a summary.

Good luck -

Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.637.9002
Fax:  415.600.1325
Ofc:  415.600.3739
evanspx@sutterhealth.org

evanspx@sutterhealth.org

Citation: As provision of HIPPA, we are all required to follow the guideance issued as per Coding Clinic - I would cite this guideline to them.

AHA Coding Clinic® for ICD-9-CM, 3Q 2012, Volume 29, Number 3, Pages 21&22

Question:
The patient presented to the Emergency Department (ED) in full cardiac arrest and respiratory failure due to an acute myocardial infarction. He was resuscitated, transtracheally intubated and placed on mechanical ventilation. The patient was admitted to the intensive care unit and after a short period he expired. The ED physician documented acute respiratory failure. However, the attending physician did not document acute respiratory failure in the health record. Is acute respiratory failure a codeable secondary diagnosis based on the ED physician’s documentation of this condition?


Answer:
Yes, code 518.81, Acute respiratory failure, should be assigned based on the ED physician’s diagnosis, as long as there is no other conflicting information in the health record. Whenever there is any question as to whether acute respiratory failure is a valid diagnosis, query the provider.

Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.637.9002
Fax:  415.600.1325
Ofc:  415.600.3739
evanspx@sutterhealth.org

paxneros

katysuegood@gmail.com

I think they are maintaining that any poss/prob dx must be in the d/c summery in order to be coded. If it was a concrete dx, we would not be having this issue.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

katysuegood@gmail.com

The discharging MD is the one who wrote the progress notes in which it is included. He just did not include that detail in the discharge summery.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 05, 2013 2:51 PM
To: Kathryn Good
Subject: Re: [cdi_talk] Possible/probable dx

I would agree Katy.

I usually tell physicians they can use the uncertainty rule as long as they validate it in the progress notes or include it in the discharge summary.

In this particular case maybe a query to the attending to see the consults documentation of Possible NPH and ask if he concurs. Because he didn't include it in DS it looks like he didn't agree w/the DX.

If he's like our docs he probably thinks he doesn't have to respond. Attending's have the hardest time understanding they are "the captain of the ship".

Don't know what kind of Retro query opportunity you have.

Thanks,

Norma T. Brunson, RHIA,CDIP,CCS,CCDS

evanspx@sutterhealth.org

Yes, but, IMO, our profession is very much based upon in-depth knowledge and application of very technical factors - I see no logic in their apparent position. The technical features and standards cited in the Official Guidelines do not support the 'logic' that 'a condition must appear in a dictated summary in order to be coded'. This is simply not true.

If that were the case, we would vastly underreport a multitude of conditions that may be chronic, but reportable and important factors for SOI, ROM, HCC, and so forth, not to mention DRG assignments.

As provision of HIPPA, we are all required to follow the guideance issued as per Coding Clinic - I would cite this guideline to them.

********************************************************************************************
AHA Coding Clinic® for ICD-9-CM, 3Q 2012, Volume 29, Number 3, Pages 21&22

Question:
The patient presented to the Emergency Department (ED) in full cardiac arrest and respiratory failure due to an acute myocardial infarction. He was resuscitated, transtracheally intubated and placed on mechanical ventilation. The patient was admitted to the intensive care unit and after a short period he expired. The ED physician documented acute respiratory failure. However, the attending physician did not document acute respiratory failure in the health record. Is acute respiratory failure a codeable secondary diagnosis based on the ED physician’s documentation of this condition?


Answer:
Yes, code 518.81, Acute respiratory failure, should be assigned based on the ED physician’s diagnosis, as long as there is no other conflicting information in the health record. Whenever there is any question as to whether acute respiratory failure is a valid diagnosis, query the provider.

Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.637.9002
Fax:  415.600.1325
Ofc:  415.600.3739
evanspx@sutterhealth.org

paxneros

Did he say NPH in the PN or Possibly NPH? Again, once that DS is done - even if he still wasn't certain - he should have included, "possible NPH". I think not including it makes it look like he no longer considered the diagnosis.

We were hit several times for this same reason by an auditor. She encouraged us to make sure it was documented in the DS. Otherwise, it looks like you are assuming the DX.

NTB

cynthia.a.goewey

Does anyone who attended the conference in Nashville remember hearing Christy Williams ("News Brief: Healthy Caridac Patients Dying at ABC Hospital") mention that "Possible" is not a codeable diagnosis anymore? I have that written in my notes. I also thought I heard someone say this in another session as well. If you heard this do you remember the reference she used?
Thanks,
Cindy

cynthia.a.goewey

Does anyone who attended the conference in Nashville remember hearing Christy Williams ("News Brief: Healthy Caridac Patients Dying at ABC Hospital") mention that "Possible" is not a codeable diagnosis anymore? I have that written in my notes. I also thought I heard someone say this in another session as well. If you heard this do you remember the reference she used?
Thanks,
Cindy

sbeatty

I heard it twice, too. I think our new word is probable.

Sandy Beatty, RN, BSN, CCDS
Director of Clinical Documentation Improvement
Community Health Network
1500 North Ritter Avenue
Indianapolis, IN 46219
317-355-2016
sbeatty@ecommunity.com

cynthia.a.goewey

Thanks so much!
Cindy

fishdl@shands.ufl.edu

There was a statement in the recently released AHIMA Guidelines for Achieving a Compliant Query Practice: “Unlike other qualifiers listed under the official coding guidelines for inpatient reporting of uncertain diagnoses, “possible” is a very broad term and therefore its use in a query is discouraged.”
Donna
Donna Fisher, CCS, CCDS
CDI Coordinator
Shands at the University of Florida
Ph: 352.265.0680 ext 48769
fishdl@shands.ufl.edu

cynthia.a.goewey

Thanks Donna. I thought I remembered her mentioning the guidelines but when I reviewed them I guess I read right over that sentence.
Thanks again,
Cindy

tkreiling

Is this from official coding guidelines? If so we will need to be changing some of our query wording at our facility.
Thanks,

Tara, RN,CCDS
le privilege.

ddouthit

Another question in line with possible/probable dx.

Patient has a progress note that says Acute Renal Failure, most likely related to ATN. Discharge summary states Acute Renal Failure. Can you pick up ATN without clarifying ruled in, rule out, resolved?

Dorie Douthit, RHIT,CCS

Unknown

I’ve always queried for clarification in this scenario.




Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
A 01923

don.cdi.rn@gmail.com

Could be coded if that "most likely related to ATN" was documented on a
PN on the day of discharge.

From Coding Guidelines:
C. Uncertain Diagnosis
If the diagnosis documented at the time of discharge is qualified as
“probable”, “suspected”, “likely”, “questionable”,
“possible”, or “still to be ruled out” or other similar terms
indicating uncertainty, code the condition as if it existed or was
established. The bases for these guidelines are the diagnostic workup,
arrangements for further workup or observation, and initial therapeutic
approach that correspond most closely with the established diagnosis.

If not on day of discharge, must query.
There is variation of opinion (level of concern) with external auditor
if documented in last PN on day of discharge but not included in DCS
...

Don
===================================

ddouthit

I am in agreement with you guys. We just underwent a DRG validation audit and there were two cases where "likely ATN" was documented in one or two progress notes but only ARF was documented on discharge summary. Audit recommendation was to pick-up ATN diagnosis instead of ARF unspecified. I thought query would be necessary in order to pick-up ATN.
Thank you for your responses and references.

Dorie Douthit, RHIT,CCS

evanspx@sutterhealth.org

I agree with Don - the guidelines permit this practice.

Having said that, it would be 'better' if the summary used the same language.

But, to relate to one of the original questions asking 'have the guidelines changed so that conditions stated at the time of discharge can't be coded?) - the answer is "no".

Clearly, this is a nuanced and difficult topic; my point has been to a somewhat larger topic - that being, simply because a condition is not stated in the summary, this alone does not disqualify said condition for coding. I restate this because I have seen denials making this claim, and that statement prima fascia is false.

There are two different issues being discussed:
1. Can we code something if it is not in the summary - the answer is clearly is 'it depends'.


2. Can we code Uncertain Conditions - see Guidelines.

Good discussion. I am simply stating one should ensure the 3rd Party is accurately stating (and employing) the Official Guidelines when the 3rd Parties issues denials.



Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org

paxneros

katysuegood@gmail.com

So here's my next question. If you have "possible ATN' in the progress notes but not the d/c summery, how are we supposed to query for inclusion if we are no longer supposed to include 'possible' in our queries?

My initial response would have been to query using language like:
'Dr_______, the diagnosis of Acute Renal Failure is included in the progress notes with further specification as 'possible ATN' this specificity is not included in the D/c summery with only Acute renal failure listed. Can you please clarify whether ATN was ruled in, out, or remains as a possible diagnosis at the time of discharge?"

However, if we are not to use 'possible' in our queries, the last part would be inappropriate. However, it feels shady to me to replace it with 'probable'. It seems like one option should be what is already in the record?

Thanks!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

tkreiling

Until coding guidelines change I am going to continue to use possible. I re-reviewed coding guidelines and "possible" is still listed in the uncertain dx guideline, along with probable, suspected, likely, and still to be ruled out. That is just my thoughts and opinion on it though and understand each facility has to do what is best for them. Not sure where the info that was shared that you shouldn't use possible came from, I understand the new brief, but where did they get that info?

Tara RN,CCDS
er applicable privilege.

evanspx@sutterhealth.org

Here is a section from the new and updated Query Guidelines:

"Unlike other qualifiers listed under the official coding guidelines for inpatient reporting of uncertain diagnoses, “possible” is a very broad term and therefore its use in a query is discouraged."


I take this to mean the specific word "possible' is not best practice when devising a query form - however, other terms, such as probable”, “suspected”, “likely”, “questionable”, or “still to be ruled out” are acceptable?


This does not mean the term 'possible PNA" if stated at the time of Discharge, is not to be coded. Coders see possible conditions noted at the time of discharge with regularity, and to state we are not allowed to code these would not be consistent with the Official Guidelines.

Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org