Unsubstantiated diagnoses

kmckaig

Am interested in how other facilities handle situations where a diagnosis is listed on the DCS but there's a question of whether the record clinically supports the diagnosis. Do you code it in the absence of an additional information from the physician? Is there a coding rule out there that you go by?

Thanks for your help,
Karen


Karen McKaig, BSN, RN, CCM, CPUR, CCDS
Case Manager
Clinical Documentation Specialist
Baxter Regional Medical Center
Mountain Home, AR 72653
870-508-1499
kmckaig@baxterregional.org

evanspx@sutterhealth.org

Should not be coded, but consider a query and possible implementation of escalation policy.
A diagnosis without underlying clinical validation should be subject to query.
Reference - Guidelines for Achieving a Compliant Query Practice (ACDIS/AHIMA)
When and How to Query
The generation of a query should be considered when the health record documentation:

* Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
* Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
* Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
* Provides a diagnosis without underlying clinical validation
* Is unclear for present on admission indicator assignment


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

natalie.esquibel

ACDIS posted the following:

ACDIS/AHIMA released “Guidelines for Achieving a Compliant Query Practice,” in the February edition of the Journal of AHIMA and the April edition of the CDI Journal. The document states that coding or CDI staff should query the physician if a diagnosis is not supported by clinical indicator(s) in the medical record. Here is the excerpt from the practice brief:

“The focus of external audits has expanded in recent years to include clinical validation review. The Centers for Medicare & Medicaid Services (CMS) has instructed coders to ‘refer to the Coding Clinic guidelines and query the physician when clinical validation is required.’ The practitioner does not have to use the criteria specifically outlined by Coding Clinic, but reasonable support within the health record for the diagnosis must be present. When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, it is currently advised that a query be generated to address the conflict or that the conflict be addressed through the facility’s escalation policy.”

Even though this is a query based on a diangosis documented in the progress notes, it gives you some direction. It is an example of a query posted on ACDIS for validating a diagnosis:

"Dear Dr. Ericson, The diagnosis of bronchitis appears in the medical record (put the location). The patient is also receiving Zithromax presumably for the bronchitis. In the next progress note or the discharge summary can you please confirm the diagnosis of bronchitis by reiterating its associated clinical indicator(s) or state if it has been ruled out?”

Natalie Esquibel, BSN, RN
Clinical Documentation Specialist
Denver Health Medical Center