Including diagnoses from the ER record
I have always coded the diagnoses the ER doctor used as reason for admission as well as the h/p and attending notes. If the attending does not pull forward a diagnosis used by the ER doctor or rule it out, I have queried for whether they wish to include or retract/rule out the diagnosis. One of my attendings has questioned this process and doesn't feel she should need to correct some of the "bogus" diagnoses the ER includes. The specific topic today was a NSTEMI that the ER said the pt had. The H/P and progress notes identified a diagnosis of A fib, CHF, High troponin I level, and CKD. I queried for whether she wished to include ore retract the diagnosis of NSTEMI. The troponins were 0.38,0.39, 0.22, CST showed no evidence of ischemia or prior MI, etc, etc. She wants me to use different format and not include the reference to the ER diagnosis if this should happen again. I am looking for suggestions of what you have done or would do given similar circumstances. (FYI she is my physician advisor, so cannot ask for that back up)
Thanks
Thanks
Comments
We as CDI have either not included it in our coding for the DRG or queried for the status of the diagnosis, e.g. current, resolved, ruled out.
Some of our coders will include a diagnosis written in the ER only as part of the DRG and some won't.
I would love to know how other institutions handle this.
Thanks!
I will be brief 2/2 time constraints, but please permit me to state that Coding Clinic has clearly stated we are to use the entire record as we 'code'. There is a specific issue that speaks to ARF noted only in the ED, and AHA states the ARF is to be coded. We all know that some patients are in the ED for extended periods of time during which the ER staff manage issues such as AKI, Encephalopathy, and ARF. As these are treated, the patient's condition improves, sometimes to the point they are not noted by the accepting MD. This does not mean they can't be coded. If you believe any thing noted in the ED needs confirmation, then consider a query. However, neither should we discount the ED episode of care.
VOLUME 29 THIRD QUARTER NUMBER 3 2012, Page 22 Emergency Department Physician’s Documentation of Respiratory FailureQuestion: 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, 2012In your scenario, you state the ED MD DID document an acute myocardial infarction. We all understand that often AMI may be later 'ruled in' or 'rule out' AFTER further diagnostic efforts are completed. Please refer to AHIMA/ACDIS Best Practice, portions of which state CDS may need to issue a query if certain documented conditions may lack clinical support. Hence, I agree w/ your action to query for confirmation of any AMI. Confounding factors are you indicate 'no new signs of ischemia'...we cite Universal Definition of AMI, available on web, and one of conditions of Acute MI includes ischemia, so it seems no MI present AFTER study.
I'd disagree w/ the sentiment expressed by your advisor that the diagnoses rendered by ED are 'bogus' given the role in ED is to stabilize and triage the patient with the understanding the ED staff will not have time to necessarily and firmly rule 'in' or 'out' all conditions. I often see various conditions stated as provisional in the ED that are later clearly ruled out, but this does not mean I ignore the ED episodes of care. Obviously some conditions take time to confirm and the ED staff is not permitted time to confirm all diagnoses. Hope this helps somewhat...no easy answer.
We also have this issue and have created a policy. If stated in the ER and clearly clinical validated and treated, we will code the condition, unless it is the Pdx or the ONLY cc/mcc. If it is the Pdx or only cc/mcc, we will send a confirmed or ruled out query to the attending with clinical indicators and treatment provided. We don't specifically provide that the ER physician documented it, only that it is documented within the record. Query template used:
"The below diagnosis was documented in the record, but is not consistently noted in subsequent documentation.
Diagnosis:
Clinical indicators:
Treatment:
----------------------------------------------------------------------------------------------------------------
Please clarify the following:
( ) The above diagnosis was monitored, evaluated, and/or treated and is a confirmed diagnosis
( ) The above diagnosis was ruled out
( ) The above diagnosis is still a likely, suspected, probable diagnosis at the time of discharge
( ) The above diagnosis was monitored, evaluated and/or treated but resolved prior to discharge
( ) Other, please specify:
( ) Clinically unable to determine
Complex issue. To me the issue a diagnosis is the strength of the documentation and the strength of clinical support. We have probably seen 'sepsis' repeatedly documented in a case without weak support, probably because notes are being copied and pasted forward without edits or refinement so as to update the clinical decision-making, response to therapy, and so forth; in many instances a condition has been ruled out, but is simply carried forward without thought.
Conversely, we may have seen acute respiratory failure noted 'only once' in the ED record in a patient with a RR of 30, severe dyspnea, treated with a aggressive therapy and with ABG values clearly supporting the condition. The patient remains in the ED for a lengthy period and the condition 'resolves' before transfer to the floor or unit. IMO, this should clearly be coded. No need for a query at all.
In my view, what can be 'different' about the ED documentation is that very often they do not have the time or luxury, nor is their mission. to definitively rule in or out something like sepsis or an MI. Rather, they will list various conditions as potentials, stabilize, triage and arrange for admission. So, we very, very often see 'sepsis' or 'potential PNA" or "possible MI" listed as 'ED D/C Conditions. If subsequent notes do not confirm the suspected conditions and the accompanying testing is not supportive, IMO, there is no need to query anyone for these suspected, but subsequently ruled out conditions.
Someone once wrote the forum stating the coders 'had made a mistake' by NOT coding Sepsis because is was 'documented in the ED". Often, there is a reason why this is the case, as above.
However, IF the ED MD does document a condition, and it is not supported, in my view a validation query is in order.
So, it is complicated and it depends on the factors above, in my opinion.
Paul Evans, RHIA, CCDS
Thank you for your quick response. I agree with what you've said, but the question at hand is this:
If the ED physician states a diagnosis that is NOT clinically supported and/or treated and the admitting/attending NEVER mentions that diagnosis, should the clinical validity query go to the ED physician or the attending?? Thanks again!
Caveat: Following is my personal opinion; as far as validation, I believe the 'validation' question should be sent to the clinician treating the patient at the time the condition is noted. In this case, the ED MD.
That person spent time with the patient, examined and managed the patient. A subsequent clinician would probably be reticent to provide input or validation for something such as a form of encephalopathy or respiratory failure that may have totally resolved at the time of transfer out of the ED.