Admission diagnoses from the ER record
Happy Friday to you!
I am wondering if any of you have had a situation (and if so, what you all do with situations) where the admission diagnoses from the ER are not clinically validated nor do the attending notes mention the diagnosis. Are you querying for them to clarify whether they wish to include the diagnosis or just not coding them? (ie: Er record says Acute on Chronic Respiratory Failure, there is no evidence of either one and that is the only place throughout the entire record where the diagnosis occurs: code it, query the attending or not code it?)
Thank you in advance!
I am wondering if any of you have had a situation (and if so, what you all do with situations) where the admission diagnoses from the ER are not clinically validated nor do the attending notes mention the diagnosis. Are you querying for them to clarify whether they wish to include the diagnosis or just not coding them? (ie: Er record says Acute on Chronic Respiratory Failure, there is no evidence of either one and that is the only place throughout the entire record where the diagnosis occurs: code it, query the attending or not code it?)
Thank you in advance!
Comments
Short answer: "yes". Coding Clinic states a coder should code the diagnoses listed by the ED physician 'unless there is dissonance or doubt about the validity of that condition. However, as with all situations, neither should anyone code a condition that is 'not clinically supported'. When I have the condition of acute respiratory failure listed 'only' the ED physician, I check to see if it meets our approved criteria for that condition. If it does, I will ensure it is coded. If it does not, I will issue a query for clinical confirmation. Given an MD in the ED may encounter and treat many conditions successfully prior to transfer, this is a common situation.
P. Evans, RHIA, CCDS
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
2018 ICD-10 Guidelines, partial:
The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis. Only this set of guidelines, approved by the Cooperating Parties, is official.
At our facility the coders and CDI review the entire record including the ED report, but only assign codes based on the documentation done by providers from admission. Our coders tell us they cannot code from the ED record. I never thought to challenge that.
You may wish to inquire with them regarding their stance. If an ED MD sutures muscle or fascia in a trauma patient, that procedure may impact DRG assignment; we count MV start times when it commences in the ED. Consider the multitude of conditions recognized and treated by the clinical teams in the ED that are resolving or resolved at time of transfer - such as ARF, to name one - that impact metrics. We all know patients can spend considerable time in the ED prior to bed assignment, allowing ample time for recognition and treatment. It may be worthwhile to review this with coding management. I can tell you I have been coding for longer than I want to admit, and we 'always, review the ED course of care and notes for coding assignment.
Best. Paul
I agree with Paul...I would take a proactive stance and take this information to coding. Many times patients present with acute conditions that are remedied in the ER and the facility should be getting credit for that.
Keep us posted on your progress.
Jeff
I have to wonder if the coder did this independently w/o reference to site policy and/or discussion with Coding Manager? I am not trying to be overly critical of the coder, but this is not as I was trained or educated. As Jeff and I state, you may wish to pursue this in a more formal manner with the coding manager, asking them for rationale, formal position on the matter. Let us know what happens?
Paul
If it is a non-CAH hospital, ED diagnoses count and are POA-Y. If there is a discrepancy or question of clinical validity, there should be a query.
Erica: I have no idea why you'd be advised as above. I am not an expert on CAH, but this seems both counter to existing coding rules as stated by AHA, but also strikes me as not logical. I'd ask for a definitive source statement.
I do review the ER notes and will query the inpatient provider for diagnoses stated on the ER note that are not included or referenced on the H&P, especially if it is with regards to respiratory failure, sepsis or other big diagnoses, but if a diagnosis is stated on he ER note and is not stated on any of the notes from the inpatient provider they would not be coded by the coder.
As a CAH, we are reimbursed differently and I know that is where a lot of these differences stem from. I was not aware of how things coded when I worked as a case manager/ utilization reviewer here and have been working with my co-workers in that department as I feel that we have to be mindful of this with our OPO population that get moved into inpatient LOC and appear to be very low risk and severity based off the diagnoses that are on that visit. Especially when many of the acute issues are resolved at that time. I am working to encourage the providers and UR to work to make the determination for inpatient more quickly when it is appropriate as we have had a tendency in the past to stretch the OPO to the limit. The CMI is still important to us and does have impact on our reimbursement over the long term, so having acute stays with really low weights due to low severity and risk are a detriment to portraying the true picture of the population we are serving here.
Now we do have a some payors that reimburse us based on the APR DRG system and for those the ENTIRE visit is rolled together (ER, OR, OPO, Acute) and for those all the diagnoses listed throughout the visit as well as all of the procedures are coded on the same claim and reimbursement is determined by that.
Clear as mud I am sure....
Jacie
The Official Coding Guidelines for ICD-10-CM state that UHDDS definitions are used by hospitals to report inpatient data elements - Federal register July 31, 1985. "Since that time the application of the UHDDS definitions has been expanded to include all non-outpatient settings" ~Coding Guidelines.
Coding rules are not different for CAH. Reimbursement methodology is different but the guidelines and code book instructions are a constant.
Thank you for your response. I agree that coding guidelines are not different for a CAH. However, being a CAH we are reimbursed and bill differently. For our Medicare population, our ER visit is billed separately from the OPO visit which is billed separately from the inpatient visit. Therefore, each is a separate hospital stay/encounter in a sense.
I realize that I didn't clarify this in my previous post and I am still trying to figure all of the differences between a CAH and typical acute care hospital. My understanding is that we apply the UHDDS definition that states "Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded" As such, if the diagnosis does not meet the definition of an "other diagnosis" during the inpatient stay (as it's own stand alone stay) due to that condition being resolved prior to the inpatient admission or not stated in the inpatient stay itself, we can not include it. Now if a provider states any evaluation, monitoring, treatment for that particular diagnosis or if the diagnosis becomes valid again at any point during the inpatient stay and meets the definition, then it would be included.
I do appreciate really appreciate these conversations as they do challenge me to review practice and double check my understanding and the history of what my understanding is.
Jacie
if a patient is treated for acute on chronic respiratory failure in the ED & got it resolved prior to transfer to the IP units & placed on just oxygen 2L//mt/NC,will you query for the MCC or just won't code it?
Thanks in advance for feedback..