Are you managing the Problem List?

lreis@gvh.org

Are any CDS's out there who are managing the Problem List at your facilities? (For those who are unclear, the 'Problem List' is the list of diagnoses that appear in the provider's notes). Thank you, in advance.

dvitalone1

We do not manage nor do we code off the problem list because majority of the time they are not updated and they auto populate into the progress note

lsipos@monument.health

Ahhhh, the ongoing problem of "the problems list". Our coders (generally) use the rule of not using the problems list for coding a diagnosis. HOWEVER, having said that, many times it is evident a diagnosis is documented on the ED record; for example the pt has the "suspicion of Pneumonia". The subsequent documentation has that diagnosis only on the problems list as "acute"-well, of course then they would use it if we can see they are treating it with abx etc. Many times though, if there is an "acute condition" on the problems list such as COPD exac but it isn’t documented anywhere else, the coders would not normally code it. And yes, those diagnosis do auto populate and many of our providers do not update them as they should-so we often have old or acute conditions from the last hospital stay or a provider inaccurately put in an incorrect acuity or diagnosis. Some providers will use the problems list entering the diagnosis/the chronicity, and then even add "how they are treating that condition" right in the problems list diagnosis! I wish they all would document that way!

So for us, NO, the coders say they "don’t" code from the problems list. The CDI will evaluate it while we are doing our reviews for clarification and query if we can support or something needs clarified from it.

We are adding "resolved, & ruled out" to the problems list options other than just the "acute and chronic". .....

Juli

don.cdi.rn@gmail.com

I'd disagree with the flat statement some will make that the problem list should not be coded from. As long as it is brought into the medical documentation, AND there is evidence of treatment, etc., then it can and should be used to capture a complete picture of the patient's acute, chronic, and past history.

There certainly are problems with maintenance among some of our providers, but the record needs to be examined in its entirety to determine appropriate coding.

We've had a technical problem at times where the problem list (free standing) was not always visible by coding, the free standing list was not apparent to have been signed by the licensed provider, etc. However, it is very commonly imported into notes, HP, etc. and there most often is evidence of editing and selection. Additionally, the rest of the context of documentation is often quite helpful for support of the diagnosis.

Don

lsipos@monument.health

Don

I agree with you, but our coders have told us they do not code from the problems list-period. So, even if the CDI sees tx in the record for a condition, UNLESS the provider brings it into the documentation somewhere; documentation, subjective, objective, assessment etc! if the CDI sees tx we then get the provider to bring it into the record so the coders will code it! The statement from our coders was that they were advised (not sure by whom) not to code "just" from the problems list, with the "just" to them meaning it was the only place a diagnosis was listed-especially and related to acute conditions I am sure. So, as our role of CDI, knowing this is their logic, we query the providers to bring it into the documentation somewhere in the chart other than JUST the problems list. And yes, we do have providers where that is the ONLY place they list a diagnosis....

Job security!

Juli

evanspx@sutterhealth.org

IMO, it is not Best Practice to code from the Problem List - this is a compilation of codes that are selected by clinicians, and I feel the conditions and codes listed are often not relevant for the particular short-term acute care setting.

From what I have seen, clinicians will sometimes list diagnoses and conditions (and codes) that are no longer relevant or active. I have seen Sepsis, acute renal failure, CVA, and a multitude of other conditions with the corresponding codes, listed as a current condition, yet the conditions listed are PAST, Resolved conditions from the PMH and pertaining to a previous episode of care.

For that matter, the same is true of conditions listed in the H&P and progress notes: a coder, using clinical review judgement, must scrutinize every potential condition(s) that 'could' be coded and assign a code only if the Definition of a Reportable Condition is met. This is one reason I am adamant that we recognize the varying levels of skill and formal education of 'coders'...advanced and credentialed coders DO take university courses in A&P, Pathophysiology, Clinical Pharmacology, and so forth.

I seen comments from members of ACDIS stating that 'coders' only take courses in Medical Terminology - this is false, and certainly not a universal truth.

As a CDI professional, I DO review the Problem List when I perform my concurrent review as this definitely helps me understand the pertinent background and mindset of the treating team.

Further, the medical staff often have no training as coders, and the codes selected have a high error rate.



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:  415.412.9421

evanspx@sutterhealth.org

martin.conroy

We view the problem list as Past Medical History. Part of our CDI education to the medical staff is that past medical history does not indicate a current medical problem requiring Management, Evaluation, Assessment or Treatment. Any condition that must be managed during the inpatient encounter needs to be documented in your assessment & plan.

Marty

don.cdi.rn@gmail.com

Juli -- agree with you in that when your professional coders have a policy stance (and one that I see the rationale for and feel is well considered, just have a nuanced disagreement with), the appropriate process for CDI is to seek to obtain the supported documentation in the record.

Paul -- I think we are mostly in agreement.
Certainly agree to NOT use the numerical codes that may be in a problem list.
A problem list (especially that is not edited for that particular stay) presents a lot of issues of diagnosis that are not relevant or are even fully resolved from prior encounters.
I think where we may disagree (??) is if the only existing narrative/diagnosis documentation is in the problem list, and it is supported by appropriate treatment, etc. documented in PNs, then it would be appropriate to code the diagnosis.

Donald A. Butler, RN, BSN
Manager, Clinical Documentation Advisor Program
Vidant Health, Greenville NC
252-847-6855

evanspx@sutterhealth.org

Hi, Don

I am not certain if one is technically 'permitted' to code a condition that clearly DOES meet reporting requirements if that condition is 'only' noted in a Problem List...that is a pertinent question/issue.

(Perhaps a representative of ACDIS could formally pose that question to AHA (Coding Clinic)?

At, our institution, at least for the time being, does insist that the diagnosis be listed in other portions of the record. However, I certainly concur one may argue that if a current and reportable condition is listed on the current problem list, it may be coded. Again, we have so many problems with the Problem List that we don't follow that practice, at least not yet.

Paul



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

gwojo

Paul,
 
This has been a consistent issue with copy/paste; physicians copying from the problem list. It can be very confusing.
 
Fran Wojciechowski, BS, RHIA, RHIT, CCDS

lreis@gvh.org

Thanks everyone for your reply, but we aort of got off topic. I was not asking whether or not your code from the problem list.

Are you Managing the Problem List at you facility? So far, I only received one answer to my question: More responses specifically to this question (only) would be helpful. Thank you!

dvitalone1

Nope we do not, it is the physician's responsibility

evanspx@sutterhealth.org

No, we do not manage the MD Problem List (not something I'd really wish to attempt, quite frankly)...if you are managing this, my hat is off to you!!

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:  415.412.9421

evanspx@sutterhealth.org

don.cdi.rn@gmail.com

Nor do we.

Additionally, I would have some concerns to very carefully think through -- exactly what role does CDI have?
**are we part of the direct care team (and thus are documenting in the clinical record)?
**does our respective professional certification/licensure also allow us to identify (or modify/manage) diagnosis?
**or are we scribes (and thus I feel the only legitimate way to document in the record is at the immediate direction of the practicing physician for each and every patient) -- in this case we'd NOT be coming up with our own diagnostic vocabulary)?

One alternative scenerio might be if the provider individaully requests a 'consult' to assist with appropriate diagnostic vocabulary -- but I feel this is so far beyond likely as to be quite an impractical scenario.

Donald A. Butler, RN, BSN
Manager, Clinical Documentation Advisor Program
Vidant Health, Greenville NC
252-847-6855

evanspx@sutterhealth.org

Then number of diagnoses listed on the Problem List seem to make the role of CDI impractical. (Simply too many patients, diagnosis, and conditions to monitor).



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

lsipos@monument.health

THE PROBLEMS LIST IS A PROBLEM....... no we do not manage either...

Juli

sharon.cooper@owensborohealth.org

I echo what Juli said "THE PROBLEMS LIST IS A PROBLEM....... no we do not manage either..."

Sharon

Sharon Cooper, RN-BC, CCS, CCDS, CDIP, CHTS-CP
AHIMA-Approved ICD-10-CM/PCS Trainer/Ambassador
Manager Clinical Documentation/Appeals

sharon.cooper@owensborohealth.org
(270) 417-4612 Office
(270) 316-9088 Cell
(270) 417-4609 Fax

Owensboro Health Regional Hospital
P.O. Box 20007
Owensboro, KY 42304-0007

gwojo

"Managing" the problem list is completely out of the scope of a CD I Specialist.

careed

We feel that CDI involvement with the problem list would be along the line of ‘leading’ the physicians. We are not part of the patient care team, and therefore, should not be documenting in the patients chart.
Thanks!
Christine

draperj

We assist Case Management with filling it in.

Julie Draper
Interim Coding & CDI Supervisor
641.428.7032
draperj@mercyhealth.com