Unsupported diagnosis

soccerballsmarty

Can someone please tell me why on this earth coders will put any diagnosis to paper that has not a shred of evidence? If the physician mis-speaks, and it happens, and states "Acute Renal Failure" and the creatinine is 0.9 and GFR is >60, it gets coded. If the condition does not exist, then how did we use resource on it, monitor it or add to the patients length of stay? I am thinking the Standards of Ethical Coding #3. states, "Assign and report only the codes and data that are clearly and consistently supported by health record documentation." Has anyone ever been prosecuted for excluding an invalid diagnosis in the reported claim?

dbutler

I see 2 branches on the logic of your question --

1 -- if the physician has established a diagnosis (not a possible / probable) and consistently documents through the record......the great majority of time there is associated support, if nothing else, the physician is 'monitoring' the condition with his time and attention and documentation, and most likely with serial labs. In this event, with solid documentation, the professional coder's hands are tied.

2 -- if the physician does not document consistently, then a query with the appropriate clinical data to reflect the renal status needs to be presented to the physician. Hopefully at that point the diagnosis can be 'clarified' as not actually having been ARF.

It isn't directly relevant if the condition exists when you ask the question of "how did we use resources on it..." -- what is relevant is whether the physician establishes a record of a diagnosis; and then if there is evidence of treatment, monitoring, etc. the coder is in a very difficult situation of having to code that diagnosis.

Yes, we are dealing with the same issue and conversation -- auditing entities are denying proper coding because the condition does not satisfy "clinical criteria" or "definitions". ARF is the prime target for this.
Our approach has been to code it when the documentation is consistent through to the DCS and query when the documentation is not firmly established (usually more than just not in the DCS).
This is a situation where an effective physician advisor could be a godsend in having these conversations with physicians or organizing the adoption of a consensus definition.

Don

soccerballsmarty

Solid feedback.



-- Steve Brush

dallend@einstein.edu

Well stated Don.
We have the same issues especially with ARF that is not supported clinically in the chart. We have lost appeals on this many times even with consistent documentation. The auditors are looking at the clinical picture.
This is an issue that should be handled doctor to doctor.

robert.hodges2

It sounds to me like an educational opportunity for the coders as well as an opportunity to improve communication between you and your coders. Having just finished doing some training for coders at other hospitals I will tell you that they don't routinely look at lab values like I, as a RN, do. They primarily look at what is documented based on my experience. I feel it's my job if I see something like this, and yes I did recently, to #1 query the provider to ask how they came to that conclusion, and #2 notify the coder of what I am querying the provider for and that I don't feel that the diagnosis is supported clinically. Good communication is key here between you and your coders.

Just my two cents.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
 
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
 
"Anyone who has never made a mistake has never tried anything new." -Albert Einstein 

Unknown

I understand what you are saying, but remember, coders cannot diagnose. That is why we have jobs--to help them with clarifications. For a coder not to code what is dictated or written is also fraud and it is not their place to question what a physician has written. I can tell you as a former HIM Director, that most physicians do not read the dictations they sign so they don't even know if something was typed wrong or if they dictated something they didn't mean to.

kshumpert

I don't know if they have been prosecuted but persecuted, perhaps...

fentona@bronsonhg.org

We have just the opposite problem. Our coders will not code a lot of what is written if they feel it did not really happen. We have had numerous discussions after pts have been discharged about thing that did not get coded. I recently had a coder tell me they didn't really think the pt had respiratory failure.....I agree our job is to clarify the record, but I do not feel that I should be asking physicians if they really think the dx they wrote is accurate. Our coders are very worried about denials and reviews. I do feel our coders do their best but because of the worry they undercode and tend to diagnose. I have found the most common rationale they give me is "well it was not in the d/c summary". I understand the d/c summary is supposed to be a summary of the stay, but in the real world it lacks a lot, especially if things resolved prior to d/c.

Amy Fenton, RN
Clinical Documentation Specialist
Clinical Operations Improvement
Bronson Methodist Hospital
601 John Street - Box 59
Kalamazoo, MI 49007
Office: (269) 341-8442
Fax: (269) 341-8330
Pager: (269) 513-3131
E-Mail: fentona@bronsonhg.org

digardsk

This sounds more like our coders. They are reticent to code something that they do not feel is supported clinically...or supported in the d/c sum. Kim

davisd2

OMG Amy!
I fight this everyday it seems. If it was not on the dc sum then for some reason it didn't happened. It could be written everyday on a 20 day stay and if the Dr that is covering or the admitting MD has a brainfart while he is dictating they will not code it. Yet if CHF pops up on the dc sum and no where else in the chart (we of course get dinged for core measures) but they will code it. I do not understand the process or how they were taught because regulations state they are to code the chart in its entirety. Not just the DC sum.