Possible, Prob., Likely diagnoses
Hello all,
I think this was discussed during an ACDIS conference call. I need to know if it was determined (based on coding guideline) that a diagnosis can only be coded as probable, possible, likely, etc. if it is stated as such in the discharge summary or death note. Is this a potential RAC denial if the terms only appear in the prog. note and not the discharge summary.
I sent a chart back to coding-- briefly, the patient was admitted with resp. failure 2/2 sepsis and MRSA PNA and was intubated/vent > 96h. The patient expired after 7 days. There was one prog. note that showed "likely due to line" and this did not appear in the discharge note. Needless to say, The final DRG was 314 (for the line sepsis) and I feel it should have been DRG 870 (Sepsis with resp failure and PNA with vent >96h.
Please advise on the guideline for coding Possible, prob, likely diagnoses. Our coders have final say but I want to know the correct way to arrive at the DRG.
Thanks,
Debbie Smith RN, CDIS-CM
I think this was discussed during an ACDIS conference call. I need to know if it was determined (based on coding guideline) that a diagnosis can only be coded as probable, possible, likely, etc. if it is stated as such in the discharge summary or death note. Is this a potential RAC denial if the terms only appear in the prog. note and not the discharge summary.
I sent a chart back to coding-- briefly, the patient was admitted with resp. failure 2/2 sepsis and MRSA PNA and was intubated/vent > 96h. The patient expired after 7 days. There was one prog. note that showed "likely due to line" and this did not appear in the discharge note. Needless to say, The final DRG was 314 (for the line sepsis) and I feel it should have been DRG 870 (Sepsis with resp failure and PNA with vent >96h.
Please advise on the guideline for coding Possible, prob, likely diagnoses. Our coders have final say but I want to know the correct way to arrive at the DRG.
Thanks,
Debbie Smith RN, CDIS-CM
Comments
This is from Coding Clinic 3Q 2005. Was it a working diagnosis/interim
diagnosis or a listed diagnosis?
Question:
The attending physician for an inpatient admission has included conditions
listed with terms such as "consistent with," "compatible with,"
"indicative of," "suggestive of," and "comparable with" in the final
diagnosis. How should these conditions be coded?
Answer:
Code these conditions as if they were established. These terms fit the
definition of an uncertain diagnosis. According to the Official Guidelines
for Coding and Reporting (Sections II and III), in short-term, acute,
long-term care and psychiatric hospitals, if the diagnosis documented at
the time of discharge is qualified as "probable," "suspected," "likely,"
"questionable," "possible," or "still to be ruled out," code the condition
as if it existed or was established. This advice should not be applied to
admitting or interim diagnoses.
Stacy Vaughn, RHIT, CCS
Data Support Specialist/DRG Assurance
Aurora Baycare Medical Center
2845 Greenbrier Rd
Green Bay, WI 54311
Phone: (920) 288-8655
Fax: (920) 288-3052
As far as RAC, I would suspect that there would be a risk with taking this case to 870 without a query to clarify from the attending whether or not that was still a possible diagnosis at the time of death (of course, would be hoping the physician would deny the likely link).
Note also, the phrasing of "at the time of discharge". Personally, I interpret that to mean any documentation at the time of discharge, not just the DCS or Death Note, so could be progress notes, consultant notes, orders, etc -- any physician documentation the day of discharge.
Don
Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com
H/P- cc: respiratory failure/ intubated in ED
imp: Pna, suspect asp., Resp failure 2/2 sepsis and PNA, Shock 2/2 sepsis with PNA, AKI, hypernatremia
*Prog note day 1- pt p/w PNA, resp. failure and shock. Resp failure2/2 sepsis and PNA, AKI, hypernatremia, Asp Pna
*Prog note 2 days later- septic shock likey line related (line POA), Resp failure 2/2 sepsis
*Prog note 4 days later- admitted with resp failure, septic shock. now stroke
*D/C summary/ death note 7 days later- presented with resp failure, intubated in ED. Cultures, 4/4 bottles with MRSA. CT showed necrotizing PNA. No documentation re: sepsis, line sepsis or shock here.
Just going on what you have I think you will have to use the 996.62. He connected the PICC Line and the Sepsis. Did they pull the line and replace it? The other thing is that it grew MRSA - which a PICC Line - through the skin - is direct access to a Staph organism.
The other option is to speak with the physician regarding his Final Dx. You could call his attention to the fact he did not list the Sepsis on his Discharge Summary as a conversation starter.
Often there are things left out of DS. Physicians just "forget" to dictate the information. Doesn't mean the Diagnosis is null and void.
Well good luck with that!! I would be interested in the final outcome - just for curiosity's sake!!