billing without a dc summary

lsipos@monument.health

Can anyone out there let me know if their institution codes, bills, and drops payments WITHOUT having a DC SUMMARY. Do you do this on all patients including DEATH charts? Do you have a policy on submitting a discharge summary, and if so, what time frame? Thanks!

Juli

Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
719-4390 (work)
786-2677 (cell)
"No Limit to Better......"
[CCDS_pin_1inch]

"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens

kmckaig

At our facility, we do not final code until DCS is on chart. Within the last year, we amended the time frame in our bylaws for DCS to be 60 days. Our coders are extremely conservative and will not code much of anything that is not included on the DCS.
Hope this helps,
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

katysuegood@gmail.com

This is a problematic area for us. Our coding dept DOES drop without discharge summaries if they are not timely (within a week or two of d/c). It does depend on the record. If the clinical picture is not perfectly clear (according to the coder) they will hold it. I review all death charts after draft coding and before they are dropped. I encourage all death charts to be held until we have a d/c summery. However, there have been occasions where they are still dropped prior to receipt of a d/c summery. However, generally only in cases (I hope) where the picture is clear. For example, if they were moved to Comfort Care and the death was entirely expected.
I personally think that we should not code records without a d/c summery. I have seen too many instances where the picture changes in the d/c summery. That being said, I understand that HIM cannot simply hold charts indefinitely. It has gotten better in the last year because we made missing documentation true 'deficiencies' with penalties if they are not submitted. That being said, I believe they are only penalized after 30 or 60 days and we usually don't hold charts this long.

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

wchenney

Our coders also have an issue with not coding things that are in the body of the medical record by not the dischg summary. I amended the policy to 72 hrs to do a dischg summary!!

rmhosler1

our institiution does not have a policy (that I am aware of) but if the
chart is complete without the dc summary they will go on and drop the
bill. I am not sure about death charts. If it is anything different than
the above, I will let you know.



Mary A Hosler MSN, RN
Clinical Documentation Specialist
Alumnus CCRN
McLaren Bay Region
1900 Columbus Ave.
Bay City, Michigan 48708
(989) 891-8072
mary.hosler@mclaren.org

"The difference between the right word and the almost right word is the
difference between lightning and the lightning bug."- Samuel "Mark
Twain" Clemens

evanspx@sutterhealth.org

It is complicated...sometimes the summary fails to mention MAJOR clinical conditions, so even waiting for all summaries is not a cure-all panacea. I have seen many D/C summaries with literally no diagnoses, simply a number of abnormal findings and labs. Even more list the Principal Dx incorrectly.



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

Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
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