discharge summaries

Unknown
in CDI Talk Archive
Is anyone else running into issues with discharge summaries? We have several physician groups who contract with an independent nurse contractor and her employees to dictate their discharge summaries. Recently, some of the private payors have denied the PDX because, even though it may be written in the H&P and every single PN, it is not included in the DC summary.

We have provided education to both the physicians and this group of nurses but the issue continues to be an ongoing challenge. Like many facilities, we don't always have the DC summary before the chart is coded.

Our current process is to query the physician/nurse if the DC summary is on the chart prior to coding and it doesn't match the rest of the record. We add a DC summary addendum with the correction.

Are there any facilities where your CDI program has taken over the dictation of the DC summaries to make sure the diagnoses accurately reflect the rest of the record?

Thanks!
Julie Doy

Comments

  • tiffany_susantiffany_susan
    edited April 2016

    To begin with, I hope you are appealing the denials. If the diagnosis is
    fully supported throughout the record, it does not have to be in the DC
    summary. I have heard software is being created that will allow CDS's to
    populate a discharge summary throughout the stay, therefore having a
    complete DC summary at the end. We have not tried this yet. I was made
    aware of it from our JaThomas consultant, something they are/have created.

    Thank You,
    Susan Tiffany RN, CCDS
    Supervisor Clinical Documentation Program
    Guthrie Healthcare System
    phone: 570-882-6094, pager #465
    fax: 570-882-6768
    email: tiffany_susan@guthrie.org
    "Twenty years from now you will be more disappointed by the things you
    didn't do than by the ones you did do. So throw off the bowlines. Sail
    away from safe harbor.Catch the trade winds in your sails. Explore. Dream.
    Discover." Mark Twain






  • dbutlerdbutler
    edited April 2016
    There was an interesting presentation at the conference with University of Washington who were the trial / development site for the JATA Clinintegris (I believe that is what they are calling it). When I saw the presentation, there were several aspects of their work that I found intriguing as well as some potentially valuable 'take home' perspectives and ideas. There were also aspects that I need to reflect on further -- where I might have some concerns especially based on the reality of physician behaviors -- about how they modeled & executed their program.
    Something I believe I will want to explore further.

    As long as the diagnosis is described in language that clearly confirms (not probable / possible), I agree, it should not be required in the DCS. BUT.....as a relevant and active diagnosis it SHOULD be in the DCS. I would definitely also considering appealing.

    Don

  • dogdog
    edited April 2016
    We are lucky if we get the discharge summaries within the required 30 days. I would point a hostile reviewer to Coding Clinic 2Q 2000 which states that physician documentation supporting diagnoses is not limited to the discharge summary.


    If we could only take what's in the discharge summary, we might as well sit on our hands until the patient leaves and just do retrospective reviews. Or burn the H/P and progress notes, since they clearly are irrelevant...right?


    Our coders will assign a chart to the "waiting for discharge summary" queue in the system, and then re-review when the discharge summary is dictated, to make sure there are no significant discrepancies.

    Renee

    Linda Renee Brown, RN, CCRN, CCDS
    Clinical Documentation Specialist
    Arizona Heart Hospital
  • dallend@einstein.edudallend@einstein.edu
    edited April 2016
    We do not handle discharge summary issues. Our analysts take of that. We are lucky we get a discharge summary within the required time period - let alone it actually reflecting the stay. The Asst. Dir. over our analysts usually handles discrepancies (if he notified by coding) - he contacts whoever dictated the dc summary and requests they add an addendum - they seem to do updates much quicker than the original dictation.

  • tpeytontpeyton
    edited April 2016
    Fortunately if my docs write ie -sepsis, pna as final diagnosis on the last progress notes and don't by chance include this in the discharge summary - my coder will still pick it up (especially if documented throughout the chart). Sometimes our charts are coded and finalized before even having a discharge summary.

    Tracy M Peyton RN, CCDS
    Bradford Regional Medical Center
    Upper Allegany Health Systems
    116 Interstate Parkway
    Bradford, PA 16701
    814-558-0406





  • Unknown
    edited April 2016
    Coders can code from the entire record and should not assume a diagnosis is ruled out simply due to absence on D/C Summary. It is best practice if record flows consistently throughout and we do teach our physicians to include all diagnoses treated in D/C summary. I wonder if they are getting information from some leadership due to RAC activity. I would attempt to get more information on the whys and include education for MDS to ensure D/C summary is all inclusive.


  • kshumpertkshumpert
    edited April 2016
    I have had RAC denials regarding documentation in the progress note that was subsequently missing in the discharge summary. I appealed these and won, citing Section III. Reporting Additional Diagnoses of the coding guidelines. We also had issues where a specialist documented a diagnosis and the attending did not add anything to the discharge summary from the provider. The attending was uncomfortable with confirming diagnoses from a provider and the liability associated with that. So, the plan in those situations is to have the attending document "other diagnoses per Dr. X". We have used this clarification for RACs to indicate that the providers are not in disagreement. Additionally, if an mcc/cc is documented in the progress notes and truly affects the treatment/care given, it should be included in the discharge summary.

    Thanks,
    Kathy
    Kathy Shumpert, RN, CCDS

    Interim Director Outcomes Management
    Clinical Documentation Improvement Specialist
    Community Howard Regional Health
    3500 S Lafountain
    PO Box 9011
    Kokomo, IN 46904
    Office 765-864-8754
    Cell phone 765-431-0123
    Fax 765-453-8447

    When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela




  • sharon.colesharon.cole
    edited April 2016
    We've actually had that happen with one of the insurance companies. Our coders will code a diagnosis if during the course of stay, there is documentation that the condition is improving and/or resolved. They do prefer it be in the discharge summary though. Can't blame them since technically it is just that - a summary of the entire stay.

    Sharon Cole, RN, CCDS
    CDI Specialist Team Leader
    Providence Health Center
    254.751.4256
    Sharon.cole@phn-waco.org


  • Unknown
    edited April 2016
    Easy solution would be to expand CDI into the realms of discharge summary reviews. A main contributing factor in patient readmissions is deficient discharge summmaries for effective handoff to post acute care. There are numerous opportunities for clinical documentation improvement in discharge summaries that expand well beyond inclusion of CCs/MCCs


  • Unknown
    edited April 2016
    We have the same issue here and I think it stems from the fact that many insurance companies only look at a discharge summary when reviewing a chart. In our facilities, the coders send post discharge queries most of the time. We have a policy that if the physician does not answer the post discharge coding query, it is sent to me as the CDI manager, and I call the physician. It seems to work well.

    Linda Haynes, RHIT, CCDS | Manager, Clinical Documentation Improvement | Legacy Health
    1919 NW Lovejoy | Portland, Oregon 97209 | 503-415-5609 | lhaynes@lhs.org


  • donna.kentdonna.kent
    edited April 2016
    Please see what my coding manager sent me in reply to these concerns:


    The basic rule for coding a confirmed diagnosis that is documented any where in the chart is stated in the guideline illustrated below: “When the documentation in the medical record is clear and consistent, coders may assign and report codes.” Therefore, it matters not whether the diagnosis is ‘repeated’ or ‘mentioned’ in the discharge summary, and this is why, in general, charts are coded, dropped, and billed, even if the discharge summary is not yet dictated or transcribed.


    There was a screen shot but it seems Lyris will not let me add.
    Donna

    Donna Kent, RN, BSN, CCDS
    Manager, Clinical Documentation Integrity Program
    Clinical Quality and Accreditation
    Torrance Memorial Medical Center
    ph.:310 784-6884  fax:310 784-6899
    donna.kent@tmmc.com


  • donna.kentdonna.kent
    edited April 2016
    The basic rule for coding a confirmed diagnosis that is documented any where in the chart is stated in the guideline illustrated below: “When the documentation in the medical record is clear and consistent, coders may assign and report codes.” Therefore, it matters not whether the diagnosis is ‘repeated’ or ‘mentioned’ in the discharge summary, and this is why, in general, charts are coded, dropped, and billed, even if the discharge summary is not yet dictated or transcribed.











    Donna Kent, RN, BSN, CCDS

    Manager, Clinical Documentation Integrity Program

    Clinical Quality and Accreditation

    Torrance Memorial Medical Center

    ph.:310 784-6884 fax:310 784-6899

    donna.kent@tmmc.com





  • vsm5629vsm5629
    Thank you so much for your input. I have received many great suggestions and have realized that we are not the only ones struggling with this issue!
  • vsm5629vsm5629
    Kathy,
    Thank you so much for your input. We, too, have been told that there have been RAC denials b/c of exclusion of dx from the DC summary. Currently, there is not a CDI that participates in RAC reviews; however, the idea has be mentioned.

    Val Miller BSN,RN,CCDS
    Georgetown Hospital System
    Waccamaw Community Hospital
    Murrells Inlet, SC
  • vsm5629vsm5629
    Agree!
  • vsm5629vsm5629
    I like this idea! Thank you!

    Val Miller BSN,RN,CCDS
    Georgetown Hospital System
    Waccamaw Community Hospital
    Murrells Inlet,SC
  • deanne_wilkdeanne_wilk
    edited April 2016
    Any diagnosis can be taken from throughout the record as appropriate. A diagnosis of "possible, probable, likely, suspected" must be documented on the last progress notes or discharge summary to constitute "at time of discharge". So the answer is yes, you would code that as acute systolic CHF.


    Deanne Wilk, BSN, RN, CCDS, CCS
    AHIMA approved ICD-10-CM/PCS Trainer

    Clinical Documentation Improvement and Inpatient Coding Manager
    HIMS Department
    Good Samaritan Health System
    4th & Walnut Sts
    Lebanon, PA 17042
    dwilk@gshleb.org

    Phone: 717-270-7582
    Cell: 717-580-1436



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