How many times must a physician document a diagnosis?

donnakellykent@gmail.com

Currently I'm working at a facility that is requiring that docs document their intended diagnoses not just in progress notes but also in discharge summaries or coders will not code it.

In the past I went by the standard that if a diagnosis was documented and there was clinical support for it, it was reportable. I'm having trouble finding anything written about that point. Can anyone guide me to something I could show them. A lot of things are not being coded because of that.
Thanks,
Donna
donna.kent@yahoo.com

elizabeth.enright@umassmemorial.org

Hi!
I am in a similar situation. I, too, came from a facility where once documented, with supporting indicators, it was coded and did not need to be in the discharge summary, unless it was a significant diagnosis. Now, at my new facility, that is not the case and so much is being missed or re-queried when it does not need to be. I also would love any feedback from the group!
Thanks,
EE

Unknown

I agree with Karen's reply on documenting a diagnosis one time only. My understanding is that there have been denials when a diagnosis is not substantiated throughout the chart. Also, if an insurance company asks for copies of the record, often they only want the discharge summary and will base their payment or denial on that one document.

Linda Haynes, RHIT, CCDS
Manager, CDI
Legacy Health
lhaynes@lhs.org

ddouthit

I have been on both the coding and CDI side.

Now that I have become a CDI, I have developed a much more defensive approach to coding due to the RAC appeal process. A couple of things.
• Probable, possible, likely diagnosis have to be picked up in the discharge summary or progress note written on day of discharge in order for coders to code. CDI (CDI does both concurrent and retro queries) coding seeks clarification retrospectively for ruled in, ruled out, resolved.
• If a diagnosis is principal, CC, or MCC and is not documented in the d/c summary and not clearly and consistently documented in the medical record. CDI seeks clarification retrospectively for ruled in, ruled out, resolved.
• Sepsis, respiratory failure, acute renal failure and encephalopathy are RAC focus diagnosis so we have educated our physicians that when they document these diagnosis they need to provide supporting clinical indicators in there dictation.
• Our evolving role as CDI specialist is to denial proof records.

Some coders are more aggressive that other coders and will go out a limb. I have found that these charts are really hard to defend in a denial. But leaving money on the table is also not a viable option. Aggressively education physicians on the importance of caring documentation thru a record is important. But also education for coding staff that if they have a diagnosis they are uncertain or don’t feel comfortable coding due to lack of physician documentation needs to go back to CDI or coding manager for a review of possible query opportunity before completely dismissing the diagnosis.

Dorie Douthit RHIT,CCS
ddouthit@stmarysathens.org

cindy.pritchett04

I have worked in a variety of settings, and the "best practice" I've seen
was one in which the hospitalist/medical staff group for the facility
developed a "How Much is Enough" internal guideline addressing this exact
problem. It was signed-off by the medical staff and distributed to BOTH
coding and CDI - so everyone was on the same page. It really cleaned
things up for that facility. When a conflict/lack of clarity would arise,
the protocol would be reviewed and followed.

This facility was in California and is/was a HEAVILY RAC targeted facility
due to their high Medicare population - so they engaged the medical staff
to drive the protocol. It was truly an outstanding successful effort -
took a while to get everyone on the same page (CDI &
coding). CDI's "burden" to get things in the record more than once
intensified, but chasing retro queries obviously reduced. If the "how much
is enough" guidelines were not met, then per the protocol, the diagnosis
was not coded. This might be a workable solution to shoot for at your
current organization.

Cindy Pritchett, RN, BSN, CCDS
MedPartners CDI Consultant

jdavis@hprhs.com

At our hospital some of the Medicare Managed Companies have been deny some cases or changing Principal Diagnois or deleting diagnoses if MD failed to document the diagnosis in Discharge Summary even though MD wrote the diagnosis daily in progress notes. Seems this becoming a new trend so that is probably why your coders are not coding. However, it seems should just have MD make addendum to D/C summary & add the diagnosis rather than not code/bill a diagnosis that was present & treated.


Janice Davis, RN CCDS
High Point Regional Health