coders picking up diagnosis

hillsandovals@email.chop.eduhillsandovals@email.chop.edu
in CDI Talk Archive
Hello CDI's

I have a question about coders. If a provider documents Acute Resp Failure on the H&P and this diagnosis does not appear again in the chart, but it is downgraded throughout the rest of the chart as RAD or resp distress, can the coders still pick this up?

I had a discussion with one of the coding managers who said that since the ARD was not seen in the rest of the chart, and the provider did not state that the ARD was resolved, the coder will only take the diagnosis that appeared throughout the chart.

Comments

  • chutchinsonchutchinson
    edited April 2016
    Coders here would not pick up the acute resp failure if it is only documented once. I don't agree with that (if there is clinical evidence to support the dx & treatment) but that is what the coding auditor & manager support here. Do I think the diagnosis should be carried through the chart? Yes, but the reality is that it usually is not. Diagnoses get dropped during transfer from PICU to the general floors. Unfortunate. (And yes I have done education, put up posters, etc. regarding importance of carrying diagnosis all the way through the record.)
    Coders here will pick up acute resp distress/diagnosis that is consistently documented in the record. We were hopeful the conversion to an EMR (versus our previous hybrid paper and electronic record) would help solve the problem because we kept hearing from the physicians that they didn't have time to write everything out every day.
    Well, we now have the problem of "Copy and Paste" where a diagnosis is only listed on Problem List and never mentioned in the body of the progress notes or DC Summary outside of the problem list. Do other places capture this diagnosis? Do you query to confirm the diagnosis or what? That is an ongoing discussion where I work because we have noticed diagnoses from previous admissions listed on the current stay's problem list that do not belong on the problem list and they are not mentioned anywhere in the record. Frustrating.

    A work in progress~ that's why I like my job....always an adventure/challenge. :-)

  • rcramos@texaschildrens.orgrcramos@texaschildrens.org
    edited April 2016
    I would probably look for a documentation somewhere stating when the patient was extubated and discuss it with your team/department if that would be good enough. There has to be a note somewhere stating planned extubation.

    Thank you.

    Raymond C Ramos
    Clinical Documentation Integrity
    Texas Children's Hospital
    832-824-3196
    rcramos@texaschildrens.org



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  • chutchinsonchutchinson
    edited April 2016
    True if pt was intubated, however not all patients in acute resp failure are intubated.
    .

  • hillsandovals@email.chop.eduhillsandovals@email.chop.edu
    edited April 2016
    Claudine Hutchinson, thanks so much for your response. It is frustrating, and being a new CDI program, we are learning new things daily as well. The one response that I got from the manager was that if the provider did not put, "Resolved Resp Failure" or "Resolved Shock", then it is not picked up. As a clinician, we know that if these things are not resolved then the pt will die, and that it is expected that the resp Failure will deescalate to resp distress. I am wondering how many patients this has not been pick up.

  • hillsandovals@email.chop.eduhillsandovals@email.chop.edu
    edited April 2016
    Hi Raymond, unfortunately, not all of our kids are intubated who have ARF. Also Raymond are you saying that the coder should look for a note that states planned extubation for the coder to presume that the Resp Failure has been resolved ?

  • rcramos@texaschildrens.orgrcramos@texaschildrens.org
    edited April 2016
    I stand corrected, yes if they are intubated.

    Raymond C Ramos
    Clinical Documentation Integrity
    Texas Children's Hospital
    832-824-3196
    rcramos@texaschildrens.org


  • hillsandovals@email.chop.eduhillsandovals@email.chop.edu
    edited April 2016
    Dr. G. thanks for responding. In this case, the child was in the ICU for 3 days, admitted from the ED, in ARF on CPAP. Unfortunately the providers on day 2 and three documented "impending ARD on Bipap". Then changed back to CPAP due to desats.

    So I just want to clarify your response. So as long as this child was still having desats and needing increased support, but it was not documented, "ARF", but impending "ARF", then it should have been coded?


    Thanks,
    Steph

  • hillsandovals@email.chop.eduhillsandovals@email.chop.edu
    edited April 2016
    Thanks Dr. G.
    We are scheduling a mtg with Pulm, ICU's and the ED providers to discuss this matter.
    Thanks for the feedback, and yes lots of training to do.
    Steph
  • chutchinsonchutchinson
    edited April 2016
    "Impending" (as I understand from talking with coding) means nothing ~ you would need to query to clarify. Acute resp failure is a battle here for CDI, a work in progress as our docs prefer "acute resp distress" but there have been a few success stories for documentation since I started. :-)

    Claudine Hutchinson RN (CDI)


  • kathryn.goodkathryn.good
    edited April 2016
    If Resp failure is in the H&P and Resp distress is throughout the rest of record this would be considered a conflict. The coder is likely going to go with what was documented later in the record, especially if it is in the discharge summary is the discharge summary trumps the progress notes/H&P as it is the final diagnostic statement. In these situations, a query should be placed to clarify whether the patient truly had resp failure or resp distress as both will not be coded on a single record in most circumstances.


    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


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