RE: dx appearing in the H&P and prog notes but noton DC summary
A couple of years ago, Medical Records Committee worked on the timeframes for various documents. Largely successful.
Current DCS requirement is within 72 hours of discharge and then any needed co-signing within 7 days of discharge.
Don
>>> "CDI Talk" 1/27/2012 9:42 AM >>>
Speaking of discharge summaries...
We are currently trying to update our physician bylaws to speed up the time that discharge summaries need to be completed by the physicians. Will you share your organization's time frame for when they need to be completed? Has this been an issue with your physicians since discharge summaries have a whole new sense of urgency thanks to the RACs?
Thank you,
Linnea Thennes, RN, BS, CCDS
Supervisor, Clinical Documentation Improvement
Centegra Health System
815. 759-8193
lthennes@centegra.com
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, January 26, 2012 10:53 AM
To: Thennes, Linnea
Subject: Re: [cdi_talk] dx appearing in the H&P and prog notes but not on DC summary
We require Principal Diagnosis to be documented on DCS but other conditions, ie CC/MCC do not have to be as long as they are not contradicted in the DCS. If the Principal Dx gets left off, we go back to the Physician to clarify and get the DCS addended as necessary.
Karen McKaig, BSN, RN, CCM, CPUR, CCDS
Case Manager
Clinical Documentation Specialist
Baxter Regional Medical Center
Mountain Home, AR 72653
870-508-1499
kmckaig@baxterregional.org
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>>> CDI Talk 1/25/2012 5:35 PM >>>
Hi,
Just wondering what everyone else is doing about dx appearing in the H&P and prog notes but then does not show up in DC summary - code or not code?
Example:
Pt admitted under hospitalist for chest pain, SOB - dx COPD exacerbation, r/o MI. Admit to tele, trend trop, usual COPD exac tx cocktail, cards consult. Cardiology saw pt and noted NQWMI in his progress notes but Attending does not write this dx in his notes nor on the DC summary. But cardiology placed pt on medical mngt for MI - ASA, Bblocker, etc.
Wouldn't it be appropriate to code NQWMI as secondary condition?
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Current DCS requirement is within 72 hours of discharge and then any needed co-signing within 7 days of discharge.
Don
>>> "CDI Talk" 1/27/2012 9:42 AM >>>
Speaking of discharge summaries...
We are currently trying to update our physician bylaws to speed up the time that discharge summaries need to be completed by the physicians. Will you share your organization's time frame for when they need to be completed? Has this been an issue with your physicians since discharge summaries have a whole new sense of urgency thanks to the RACs?
Thank you,
Linnea Thennes, RN, BS, CCDS
Supervisor, Clinical Documentation Improvement
Centegra Health System
815. 759-8193
lthennes@centegra.com
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, January 26, 2012 10:53 AM
To: Thennes, Linnea
Subject: Re: [cdi_talk] dx appearing in the H&P and prog notes but not on DC summary
We require Principal Diagnosis to be documented on DCS but other conditions, ie CC/MCC do not have to be as long as they are not contradicted in the DCS. If the Principal Dx gets left off, we go back to the Physician to clarify and get the DCS addended as necessary.
Karen McKaig, BSN, RN, CCM, CPUR, CCDS
Case Manager
Clinical Documentation Specialist
Baxter Regional Medical Center
Mountain Home, AR 72653
870-508-1499
kmckaig@baxterregional.org
CONFIDENTIALITY NOTICE
This message and any included attachments
are from Baxter Regional Medical Center and
are intended only for the addressee. The information
contained in this message is confidential.
Unauthorized viewing, forwarding, printing, copying,
distribution, or use of such information is strictly
prohibited and may be unlawful.
If you have received this transmission in error, please
promptly delete this message and notify the
sender of the delivery error by e-mail or you
may call Baxter Regional Medical Center in
Mountain Home, Arkansas, U.S.A. at (870)508-7357.
>>> CDI Talk 1/25/2012 5:35 PM >>>
Hi,
Just wondering what everyone else is doing about dx appearing in the H&P and prog notes but then does not show up in DC summary - code or not code?
Example:
Pt admitted under hospitalist for chest pain, SOB - dx COPD exacerbation, r/o MI. Admit to tele, trend trop, usual COPD exac tx cocktail, cards consult. Cardiology saw pt and noted NQWMI in his progress notes but Attending does not write this dx in his notes nor on the DC summary. But cardiology placed pt on medical mngt for MI - ASA, Bblocker, etc.
Wouldn't it be appropriate to code NQWMI as secondary condition?
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: kmckaig@baxterregional.org
If you would like to be removed from CDI Talk, please send a blank email to
leave-cdi_talk-12511794.7eefa1ab14e9ecd987cf6844293dde43@hcprotalk.com
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Copyright 2010
HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945
CONFIDENTIALITY NOTICE
This message and any included attachments
are from Baxter Regional Medical Center and
are intended only for the addressee. The information
contained in this message is confidential.
Unauthorized viewing, forwarding, printing, copying,
distribution, or use of such information is strictly
prohibited and may be unlawful.
If you have received this transmission in error, please
promptly delete this message and notify the
sender of the delivery error by e-mail or you
may call Baxter Regional Medical Center in
Mountain Home, Arkansas, U.S.A. at (870)508-7357.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: lthennes@centegra.com
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Copyright 2010
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________________________________
This transmission may contain information that is privileged, confidential, or exempt from disclosure under applicable law. If you are not the intended recipient, consider yourself notified that any disclosure, copying, distribution, use, or reliance on this transmission is STRICTLY PROHIBITED. Please destroy this transmission in any format and notify the sender, if you received this transmission in error. Thank you.
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If you would like to be removed from CDI Talk, please send a blank email to
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The contents of this e-mail (and any attachments) are confidential, may be privileged and may contain copyright material. You may only reproduce or distribute material if you are expressly authorized by us to do so. If you are not the intended recipient, any use, disclosure or copying of this email (and any attachments) is unauthorized. If you have received this e-mail in error, please notify the sender and immediately delete this e-mail and any copies of it from your system.
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Comments
Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens