Editing H/P to include diagnosis

bbogda@morrishospital.org

The scenario is that a patient with chronic respiratory failure and COPD comes in with exacerabation, but the doctor does not say acute resp failure until the next day.  Both pulmonology and the attending say acute resp failure present on admission in each progress note and the attending puts it on the discharge summary.
Because it is not on the ED report or the H/p the coder does not want to assign as Pdx.  She will put as secondary.  I told her that the acute phase was resolved by the time he wrote it, so it doesn't make sense to code as secondary.  She wants the doctor to amend the H/P to include resp failure.  I don't feel comfortable asking him to do an amendment to his document for this reason.  Is this something you would do? 

cindys@hollandhospital.org

No --Acute respiratory failure is documented and POA.  This is his diagnosis after study and well documented

evanspx@sutterhealth.org

REF  Pg 113 of 2018 ICD-10 Official Guidelines
So long as the clinical presentation at the time of presentation 'supports' the acute respiratory failure, and the record subsequently states same, there is no issue or problem, no need to edit a record (not advised) nor query.***************************************************************************************************************************There is no required timeframe as to when a provider (per the definition of "provider" used in these guidelines) must identify or document a condition to be present on admission. In some clinical situations, it may not be possible for a provider to make a definitive diagnosis (or a condition may not be recognized or reported by the patient) for a period of time after admission. In some cases it may be several days before the provider arrives at a definitive diagnosis. This does not mean that the condition was not present on admission. Determination of whether the condition was present on admission or not will be based on the applicable POA guideline as identified in this document, or on the provider’s best clinical judgment.
Paul Evans, RHIA, CCDS

fishdl@shands.ufl.edu

Agree with Paul's post.  From a denial prevention standpoint, be sure the clinical presentation truly reflects acute respiratory failure, and not just a COPD exacerbation.

evanspx@sutterhealth.org

Simple example: Psents with chest pain and MD documents long list of potentials, to include AMI>. Next day cardio examines labs , EKG and documents AMI.Even though the term not stated on admit, after study, clearly supported as Present on Admission.

Paul Evans, RHIA, CCDS

matthewayinde@hirecdi.com

bbogda@morrishospital.org said:

Because it is not on the ED report or the H/p the coder does not want to assign as Pdx.  She will put as secondary.  I told her that the acute phase was resolved by the time he wrote it, so it doesn't make sense to code as secondary.  She wants the doctor to amend the H/P to include resp failure.  I don't feel comfortable asking him to do an amendment to his document for this reason.  Is this something you would do? 

This scenario is reminiscing of a case that was discussed with my colleagues at a hospital I was a contractor.  The auditors at this insurance company looked at the time the H&P was documented and downgraded a sepsis PDx to a secondary diagnosis. They argued that how can the hospital proof this occurred on admission if the H&P was not written until two days into the admission.
It was clear Sepsis was present on admission and should rightfully be PDx, but they still found a tactic to downgrade DRG. Off course the case was appealed, and the hospital won. My point here it is good practice to include all significant diagnosis present on admission in the H&P and best practice to dictate H&P within 24 hours of admission. It is vital for continuity of care and one less hassle for a CDI specialist. To Paul's point, sometimes it takes more than a day to determine the PDx, so it is not in the ED or H&P note but once the diagnostic process leads to a definite PDX, the provider needs to state thought process and the means he or she arrived at the PDx. I also agree no need to amend documentation based on POA definition. 
Just when you think you have seen it all insurance companies pull another trick on you...

sadeluca@pcrmc.com

This scenario would not need a poa query for thoroughness?  I would ask for an addendum to discharge summary if attending decided the dx was poa...if the coder questioned, this would answer and in an audit, it would be addressed if questioned.