rule in/out query and resolving conditions

katysuegood@gmail.com

on our current rule in/out template we provide the options of:

• rule in
• rule out
• resolved
• resolving
• other
• unable to determine 

We use this template when a condition is documented early in the documentation but not carried through, dropping out of the documentation at some point in the stay. We recently had a new (to us) coder tell us that when a provider responds with resolving/resolved she will not code the diagnosis because she does not feel it confirms an active diagnosis. She interprets the documentation of 'resolved' as meaning it is no longer present but does not confirm that the diagnosis was ever present during the admission.

She also stated that she hasn't seen queries formulated in this way.

Opinions??

Katy

evanspx@sutterhealth.org

I have to say her position is not logical to me at all.  Clearly, a condition that met criteria, such as acute renal failure or acute respiratory failure, and 'resolves' with treatment is reportable.   I really don't how to debate the logic with an issue that is so self-explanatory?  We use the same wording in a very similar query with great regularity and this has never been an issue with our coding colleagues.

Paul

morris-jeff@CooperHealth.edu

I don't agree with that logic at all, but had similar thing come up so changed wording on query to treated and resolved....the addition of "treated" seems to remove any doubt for those who were doubting the diagnosis.

Hope this helps, 
Jeff 

evanspx@sutterhealth.org

The diagnosis of (diagnosis) was documented on (Date), but is not consistently noted in subsequent documentation

 

PLEASE CLARIFY THE FOLLOWING:

• The above diagnosis was present and is now resolved

• The above diagnosis is present

• The above diagnosis was ruled out

• The above diagnosis is likely, suspected or probable

• Other***

• Unable to determine

Likely, suspected and probable diagnoses should be documented as such in the discharge summary.

Submitted:  Paul Evans, RHIA, CCDS

cmclose@saintfrancis.com

I use a query similar to Paul's to see if it was present & has resolved, was ruled out (and if so, I give them a chance to document a revised diagnosis if appropriate related to the clinical findings & treatment), or still a possible diagnosis that is being monitored/treated and/or evaluated. And of course: other (specify), unable to determine.

I don't agree with the coder's logic above (from Katy's post).

teresa.siler@advocatehealth.com

I frequently use a similar query to clarify the status of a diagnosis that has dropped from the documentation.  Sometimes it is a "probable" or "likely" that was never confirmed, or it was an answer to a query documented once.  Our coders will not code a diagnosis not appearing in the DS unless is is consistently documented through the record