Coding from Diagnosis List

morris-jeff@CooperHealth.edu

I've posed this question to a few individuals but wanted to open it up to the forum.

We went live with Cerner on 10/1 and I was just wondering what everyone does with the diagnoses on the diagnosis list in your EMR. Currently, they look "ok" and are somewhat valid, but I can see the list getting very cluttered down the road, especially with frequent flyers.

Does anyone have a policy or guidelines on when your facility chooses to code from the diagnosis list? I was thinking that if the diagnosis meets criteria for a diagnosis, then we should be able to pick it up but Coding Managers have differing opinions. Currently, I am on the fence about what to do.

I appreciate any and all comments.

Thanks, Jeff

cmclose@saintfrancis.com

Hi Jeff~

The Problem List is a "problem" at our facility since it is usually not kept updated, especially on the frequent fliers, and Copy & Paste is used frequently by physicians (and residents) here. So our HIM manager decided coders are not to code from the Problem List without the diagnosis being documented somewhere in the body of the record (H&P, progress notes or DC Summary) and not just on the Problem List, otherwise a query should be sent to confirm if the diagnosis is present during the current admission (per coding manager's decision). I don't necessarily agree with this and will capture the code if it meets guidelines for a 2nd diagnosis.

Will be interesting to see what other CDI/coding staff are seeing and how they are handling it or if they have a written policy.

Thanks~

Claudine 

evanspx@sutterhealth.org

Hi, Jeff & Claudine:  My experience very similar to Claudine's.  The Problem List is not reliable and accuracy suffers as a result of 'cut, copy, and paste'.  IF we see something on the Active Problem List that IS supported, it is coded.  If we see a significant condition that is not supported, a query would be required for it to be coded. 

Paul

jackietouch@aol.com

Seems like this a common issue. Our experience is similar. Problems assigned an "active" status on the problem list automatically populate the H&P and some consult notes (the way our Cerner system is configured-Dynamic Doc notes only, not sure if it is the same everywhere). So, I pretty much practice as Paul and Claudine do. The challenge is that no one manages the problem list with any regularity, so pretty soon you will find all three degrees of malnutrition and all listed as active problems (which then will require a query to specify degree managed for the current encounter). If I am rounding and there is time, I will assist the team in assigning the appropriate status to the diagnoses in the problem list (for example, if all three degrees of malnutrition are "active", I will clarify appropriate degree for current encounter, then assist the residents in changing status to resolved on the others).

The other issue with our configuration of Cerner (again, not sure yours is the same): We have an "annotated display" and a "clinical diagnosis" field for active diagnoses and problem list diagnoses. We cannot capture diagnoses from the "clinical diagnosis" field because these do not populate the progress notes and are often incorrect (for example, progress note narrative documents intractable epilepsy, annotated display just says epilepsy, and clinical diagnosis says epilepsy, not intractable. We will capture intractable because it is in the body of the notes.

Thanks for listening to my 2 cents: Probably more info than you needed or wanted!!!

Jackie 

jackietouch@aol.com

Oops, sorry...we do not have a written policy/procedure regarding this, but it is not a bad idea in order to maintain consistency.

rwillcutt

The problem list is the one we do not code from because it travels from encounter to encounter and is rarely maintained.   The diagnosis list should not be a problem because it should not repopulate in every encounter. It should start blank.  At least that's what Cerner at my old employer.