Problem lists/codes in notes

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
As we are probably all getting further into our EHR's, meaningful use, etc, I want to revisit a question I believed we have discussed before.

Is anyone using Cerner for their EHR? If so how are you populating your notes with this information. Nursing has been populating 'problem lists' for over a year now but we just implemented the MD's 'Diagnosis list'. The plan of course is for this list to be used to populate the progress notes (PowerNote or Dynamic Doc). However, I just was in a meeting with IT and they currently have BOTH the problem list and the Diagnosis list autopopulating into Dynamic doc notes. When the note is complete bother the problem list(populated by nursing) and the dx list (populated by the MD) are in the note and then the note is signed by the MD. In my mind, this means that both lists are potentially codeable (assuming they meet guidelines for inclusion as a secondary dx). Prior to this meeting my understanding was that only dx on the 'dx list' would end up in the physician note so this came as a surprise. This makes me a bit uncomfortable but I am curious how other users view this or if they are using this the same way.

Also, are there any problems you foresee with MD's including codes (in addition to documentation) into their notes? For example, if your MD documentation software populates a I-9 (or I-10) codes when physicians input dx and this doesn't match their narrative is this a problem?

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

Comments

  • cmorellcmorell
    It is my understanding that code assignment cannot be made from physician codes. Code assignment is based on physician documentation.
    So if a physician documents 428.21 CHF -that coding cannot assign 428.21 unless physician documentation of Acute Systolic CHF is in the record.
    And of course if it is not clinically supported it will be a target for denial.

    Charlie Morell
  • annnd2009@gmail.comannnd2009@gmail.com
    edited April 2016
    I'm not sure what you mean by "unless physician documentation of Acute Systolic CHF is in the record." This is new for me where docs are choosing codes and the diagnosis and the code is in the progress note...wouldn't that be considered " in the record" ...? It definitely creates some issues as I have heard physicians say "sometimes I just have to choose one cause I can't find what I want" It's similar to CDI sometimes we just CHOOSE in the encoder, but ours are not part of the permanent record. I am very interested in all view points on how problem lists are viewed and utilized.

    Ann Donnelly,RN,BSN,CCDS
    ann.donnelly@sclhs.net

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Yes. Agree that we must code based on their documentation, not MD code assignment. I am just wondering if there is any problem with the code assigned being different than the one they chose. I think it is more likely that the reverse scenario will happen. Ex: Md assigns an unspecified code out of their 'favorites' but there is also documentation in the record supporting a more specific code which is then assigned by the coder (appropriately).

    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

  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited April 2016
    We really prefer that there not be ICD-9 codes associated with the problem list (especially since these are Snowmed for us, not pure ICD-9). There is some concern about that. However, whatever code is assigned by the facility coder I think will be defensible by the narrative documentation -- whether it is more or less than any code placed by the physician.

    I'd really prefer that the nursing history is used to inform the physician's problem list -- that the physician selects and imports those elements he believes are relevant. I'd have some concerns about any elements that 'auto-populate' into a note and then are signed. One of the extra pressures on the coding staff (and CDI) is to recognize each documented element that is actually REPORTABLE, my sense is that this has been a mildly increasing concern/focus recently.

    Don

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