coding only from discharge diagnosis

jenniferan@mcmc.net

Can anyone please guide me on what to do with this issue.

I work in a small hospital where the hospitalists work a week, take a week off then return but may not be the attending for that week, they may be on swing or night shift. I am querying for the 1st week that the patient is in the hospital and obtaining a lot of agreement which is either adding more specificity, a CC or an MCC. The patient may not get discharged until the following week or maybe 3 weeks later as they have had further issues. The second or third physician on for that patient during the following weeks are busy writing their own assessment and plan based on their weeks and are unaware that I have queried and that I have had agreement.

The inpatient coder states that she cannot code it unless it is written in the discharge summary. I am now finding that I am having to send further queries out confirming that this diagnosis was queried, agreed upon and because of that, can they please place it in their prog note and/or d/c summary, or if it is not included in the d/c summary, and because it has not been coded, I am having to approach them after the fact to make an addendum. This is adding extra work for me. My docs are stipulating that they are so busy with patients that they do not always include other diagnosis and treatment from other physicians, especially if it has been resolved. They state that if it is in a progress note being evaluated and treated, then it should be coded regardless of whether they have remembered 3 weeks later to place it in the d/c summary.

Any feedback would be gratefully appreciated as I am becoming a little frustrated with being caught in the middle.

Thank you

Jennifer

evanspx@sutterhealth.org

Hello...some institutions may adopt a practice that a condition will not be coded unless mentioned in the summary, however, there is no regulatory requirement for this practice, nor is there anything in AHA Coding Clinic also stating this is a requirement...there is a Coding Clinic speaking to this issue...refer to AHA Coding Clinic,  2012, 3rd Quarter pg 22.   VOLUME 29 THIRD QUARTER NUMBER 3 2012, Page 22 Emergency Department Physician’s Documentation of Respiratory Failure

Question: The patient presented to the Emergency Department (ED) in full cardiac arrest and respiratory failure due to an acute myocardial infarction. He was resuscitated, transtracheally intubated and placed on mechanical ventilation. The patient was admitted to the intensive care unit and after a short period he expired. The ED physician documented acute respiratory failure. However, the attending physician did not document acute respiratory failure in the health record. Is acute respiratory failure a codeable secondary diagnosis based on the ED physician’s documentation of this condition?

Answer: Yes, code 518.81, Acute respiratory failure, should be assigned based on the ED physician’s diagnosis, as long as there is no other conflicting information in the health record. Whenever there is any question as to whether acute respiratory failure is a valid diagnosis, query the provider.

Coding advice or code assignments contained in this issue effective with discharges September 15, 2012.

jenniferan@mcmc.net

thank you Paul. I am so grateful for this information

morris-jeff@CooperHealth.edu

My comment was going to be the same as Paul's, there are no regulatory requirements stating something must appear on the discharge summary for it to be coded, unless it's an inconclusive dx.

I'd suggest talking with the Coder (I'm sure you already have), maybe they have seen a good many denials based on insurance companies stating a dx must be on the discharge summary. Would be good to get their point of view.

If you are like me, we are still in a hybrid record and struggle to get those dx's in the record. We encourage the MD's to carry forward those dx's in their progress notes with the hopes that they will make it to the discharge summary (just so there won't be any questions about it)...but in reality a lot of the dx's never make it there.

It sounds as if you are running yourself ragged and not doing much for Physician engagement. I hope the situation improves for you soon! CDI Talk is a great place to get info!

Jeff

jenniferan@mcmc.net

Thanks Jeff. I have had a really good response with the physicians but it is frustrating when you have worked hard to get the query out, they agree, it adds an CC/MCC to the patient record and then it does not get coded 2-3 weeks later because it is not written in the discharge summary and there is another attending providing care.

evanspx@sutterhealth.org

Ask to see if your site has an official policy speaking to this, or is this the practice of one individual.  RE: Insurance Company denial of a condition not contained in summary: No real logical basis for this to happen, however, seems we all experience these types of denials.  Search the ACDIS data base and I imagine you will find some articles speaking to responding to denials.   It is my belief there is no defensible reason an entity can 'deny' something like ATN that is clinically supported, noted clearly, and treated, but not in the final statement.  We all know many major conditions may resolve w/ care prior to discharge..this strikes me as unfounded practice by Insurance Carriers. 

jenniferan@mcmc.net

already in hand. Thanks Paul

stephaniehaase

We have the same practice at our facility without supporting P and P's.  Allegedly, insurance companies are mandating all diagnoses in the discharge summary.  So the powers that be have included Medicare discharge summaries even though we've quoted documentation by Medicare which indicates only in matters where the diagnoses are conflicting should a query be issued.  But no guidance suggesting all diagnoses should be in the discharge summary. Luckily our CDI is not responsible for those types of queries.

thank you for your input

take care