coders picking up diagnosis
Hello CDI's
I have a question about coders. If a provider documents Acute Resp Failure on the H&P and this diagnosis does not appear again in the chart, but it is downgraded throughout the rest of the chart as RAD or resp distress, can the coders still pick this up?
I had a discussion with one of the coding managers who said that since the ARD was not seen in the rest of the chart, and the provider did not state that the ARD was resolved, the coder will only take the diagnosis that appeared throughout the chart.
I have a question about coders. If a provider documents Acute Resp Failure on the H&P and this diagnosis does not appear again in the chart, but it is downgraded throughout the rest of the chart as RAD or resp distress, can the coders still pick this up?
I had a discussion with one of the coding managers who said that since the ARD was not seen in the rest of the chart, and the provider did not state that the ARD was resolved, the coder will only take the diagnosis that appeared throughout the chart.
Comments
Coders here will pick up acute resp distress/diagnosis that is consistently documented in the record. We were hopeful the conversion to an EMR (versus our previous hybrid paper and electronic record) would help solve the problem because we kept hearing from the physicians that they didn't have time to write everything out every day.
Well, we now have the problem of "Copy and Paste" where a diagnosis is only listed on Problem List and never mentioned in the body of the progress notes or DC Summary outside of the problem list. Do other places capture this diagnosis? Do you query to confirm the diagnosis or what? That is an ongoing discussion where I work because we have noticed diagnoses from previous admissions listed on the current stay's problem list that do not belong on the problem list and they are not mentioned anywhere in the record. Frustrating.
A work in progress~ that's why I like my job....always an adventure/challenge. :-)
Thank you.
Raymond C Ramos
Clinical Documentation Integrity
Texas Children's Hospital
832-824-3196
rcramos@texaschildrens.org
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Raymond C Ramos
Clinical Documentation Integrity
Texas Children's Hospital
832-824-3196
rcramos@texaschildrens.org
So I just want to clarify your response. So as long as this child was still having desats and needing increased support, but it was not documented, "ARF", but impending "ARF", then it should have been coded?
Thanks,
Steph
We are scheduling a mtg with Pulm, ICU's and the ED providers to discuss this matter.
Thanks for the feedback, and yes lots of training to do.
Steph
Claudine Hutchinson RN (CDI)
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