Dx not in discharge summary

tkreilingtkreiling
in CDI Talk Archive
After reading the blog today, it has caused me to be a bit concerned on our process. Are there many of you that have been hit by RAC's for a dx not being listed in discharge summary? Also, we routinely may have a dx clarified on the query and that be the only place it is documented, for example CHF is documented so we query for type and acuity--which the doctor answers but that is the only place the specifics are. Has anyone had issues with RAC's taking back on that type of situation. Any information you may have is appreciated!
Thanks,
Tara

Comments

  • tmcginn@northshore.orgtmcginn@northshore.org
    edited May 2016
    Yes, our RAC's have sent us letters asking for a DRG change d/t diagnoses not being listed in the discharge summary.

    We appeal those under the grounds that there is no coding guideline that states that *everything* must be in the discharge summary in order to be coded. We also reference a coding clinic from first quarter 2004 p18-19 that states that as long as there is no conflicting documentation that a dx stated by another MD (such as a consultant physician) can be used.

    In our appeal letters we state the following: "There is no official coding guideline which indicates that the attending physician must document a diagnosis in the discharge summary in order to report the condition. Consultation reports and progress notes are appropriate source documents to code from; especially when there is no contradiction among the reports."

    We have been appealing these and winning.

    Although we try to steer docs to being more thorough and specific in their d/c summary, it is just not always possible 100% of the time.

    Tricia McGinn, MBA, BSN, RN
    Director, Documentation Integrity
    NorthShore University HealthSystem
    4901 Searle Parkway, Suite 330
    Skokie, IL 60077
    Phone: 847-982-4212
    Fax: 847-982-4273
    tmcginn@northshore.org


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