"the principle diagnosis is...."

Full of questions this morning!

We are having some doctors now document what the Pdx is. It just started happening and I am assuming they are using some sort of new documentation assistant tool that is prompting them for this. Often this is being documented in the H&P and often carried through to later documentation.
Of course the problem with this is that physicians (for the most part) do not understand sequencing guidelines so what they think is the Pdx may not be what we think it should be. For example: the patient may have come in with multiple issues that meet PDX criteria but they select the one that carries a lower RW. Or the patient may come in with sepsis 2/2 to PNA and they say the Pdx is PNA.
In cases where there is clear sequencing guidelines (sepsis must be sequences first) I am confident coding will code according to the guidelines rather than the what the MD says. However, in other circumstances, like multiple possible PDX options, I am concerned this documentation may be problematic.

What are your thoughts on this? Are other providers documenting this way?

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

  • Dr. G is spot on regarding MD designation of principal diagnosis. It is not practical to expect an MD to know the 'coding rules'...also not fair to think they would need or want to think in this manner, IMO. In our training, we rather encourage the staff to 'be as specific as possible in regards to documentation diseases'...the CDI Teams and Coders know how to code precise documentation.

    I feel that if we talk to our Docs about 'coding', they shut down - I understand why this is so. I shut down when IT tells me I can't log in because my 'baud rate' is impaired, too.

    PE

    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



  • Thanks so much Paul and Dr. G., I appreciate your guidance. I agree that the MD's don’t know (and shouldn’t need to know) sequencing guidelines. I was more concerned that coders may feel like they need to go with what the MD says. From what you are saying, I am understanding that this concern is likely unfounded and that it would be unlikely that coding would not feel comfortable coding a Pdx that was different than the physicians stated Pdx.

    Thanks for the help!

    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

  • As always, agree w/ you, Katy: Below is an excerpt from an excellent coding manual. As you stated, the coder should not rely solely upon MD designation of PDX. If/when the PDX can’t be determined with a complete review, a query may be necessary. I often code charts that totally lack any ‘final diagnoses’ whatsoever w/ a dictated summary, and obviously this complicates the coding task.







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    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



  • edited April 2016
    I think ICD10 has brought some new light as far as physicians, CDI and coding. I have had more physicians interested in coding than ever before. My opinion is that they go hand in hand. You also have many physicians out there that are speaking and educating on CDI that do not have adequate coding and guideline knowledge and at times this creates discord with the knowledge and advice they are promoting.

    Deanne Wilk, BSN, RN, CCDS, CCS
    AHIMA approved ICD-10-CM/PCS Trainer

    Clinical Documentation Improvement and Inpatient Coding Manager
    HIMS Department
    Wellspan Good Samaritan Hospital
    4th & Walnut Sts
    Lebanon, PA 17042
    dwilk@gshleb.org

    Phone: 717-270-7582
    Cell: 717-580-1436




  • edited April 2016
    In few of our facilities pt is being placed on observation for day or so, and then rolled to inpatient for unknown reason. Sometimes, it easy to determine, for example if pt had outpatient procedure done, and something happened during or after procedure, and pt is rolled to inpatient for that reason. I am not talking about these cases. These are most easiest cases to determine. However, in instances where pt was on observation and then rolled to inpatient for another reason(s). What do you do in this case? I think, we have no choice but to query the doc for reason for inpatient admission. Some of our docs are very resistant to these queries, and I don't blame them. But do we do??
    Does anybody have any suggestion?

    Anna Rozhkovskaya, RHIT, CCS, CCS-P
    Manager, Clinical Documentation Improvement
    Memorial Healthcare System

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