Coding Guidelines
Can anyone tell me where (if any place) in the guidelines it states that in order for a code to be coded/billed, it must be listed in the Discharge Summary? We are receiving managed care denials/rejections for codes that are coded but not mentioned in DC Summary. This sometimes happens when a condition in present early in the stay but resolves and is not mentioned in DC Summary. The ACDIS Boot Camp training earlier this spring indicated that "guidelines say a code only has to be documented one time if supported by clinical indicators. Being in the discharge summary is not a requirement but different organizations are making up their own rules (such as RAC)".
I found a coding clinical first qtr 2004 that indicates:
Question: Please provide clarification regarding the appropriateness of code assignments based on the documentation in the medical record by a physician other than the attending physician. Previously published Coding Clinic advice has allowed using documentation from the anesthesia report. Our coders have interpreted that the lack of contrary documentation from the attending can be perceived as concurrence with the anesthesiologist. We have recently been advised that we cannot use a consultant's note without "confirmation" from the attending physician. Our coders tell us that it is operationally impossible to confirm every single diagnosis or condition that the consultant writes. Of course, if there is conflicting information, we will query the attending physician for clarification. Can you comment on whether our interpretation of coding instructions is correct?
Answer: "Code assignment may be based on other physician (i.e., consultants, residents, anesthesiologist, etc.) documentation as long as there is no conflicting information from the attending physician. Medical record documentation from any physician involved in the care and treatment of the patient, including documentation by consulting physicians, is appropriate for the basis of code assignment. A physician query is not necessary if a physician involved in the care and treatment of the patient, including consulting physicians, has documented a diagnosis and there is no conflicting documentation from another physician. If documentation from different physicians conflicts, seek clarification from the attending physician, as he or she is ultimately responsible for the final diagnosis. This information is consistent with the American Health Information Management Association's (AHIMA) documentation guidelines."
This CC seems to indicate to me that if a consultant documented a Dx in a progress note but the attending did not place it in the DC Summary it would still be okay to code it as long as there were no conflicting diagnoses between the 2 physicians. Any thoughts????
DISCLAIMER: The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for use by the intended recipient. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. The partaking of any action in reliance upon this information by persons or entities other than the intended recipient is illegal and a violation of the regulatory guidance in the Health Insurance Portability and Accountability Act (HIPAA). If you received this in error, please contact the sender immediately and delete the material from all computers.
I found a coding clinical first qtr 2004 that indicates:
Question: Please provide clarification regarding the appropriateness of code assignments based on the documentation in the medical record by a physician other than the attending physician. Previously published Coding Clinic advice has allowed using documentation from the anesthesia report. Our coders have interpreted that the lack of contrary documentation from the attending can be perceived as concurrence with the anesthesiologist. We have recently been advised that we cannot use a consultant's note without "confirmation" from the attending physician. Our coders tell us that it is operationally impossible to confirm every single diagnosis or condition that the consultant writes. Of course, if there is conflicting information, we will query the attending physician for clarification. Can you comment on whether our interpretation of coding instructions is correct?
Answer: "Code assignment may be based on other physician (i.e., consultants, residents, anesthesiologist, etc.) documentation as long as there is no conflicting information from the attending physician. Medical record documentation from any physician involved in the care and treatment of the patient, including documentation by consulting physicians, is appropriate for the basis of code assignment. A physician query is not necessary if a physician involved in the care and treatment of the patient, including consulting physicians, has documented a diagnosis and there is no conflicting documentation from another physician. If documentation from different physicians conflicts, seek clarification from the attending physician, as he or she is ultimately responsible for the final diagnosis. This information is consistent with the American Health Information Management Association's (AHIMA) documentation guidelines."
This CC seems to indicate to me that if a consultant documented a Dx in a progress note but the attending did not place it in the DC Summary it would still be okay to code it as long as there were no conflicting diagnoses between the 2 physicians. Any thoughts????
DISCLAIMER: The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for use by the intended recipient. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. The partaking of any action in reliance upon this information by persons or entities other than the intended recipient is illegal and a violation of the regulatory guidance in the Health Insurance Portability and Accountability Act (HIPAA). If you received this in error, please contact the sender immediately and delete the material from all computers.
Comments
If it was a definitive diagnosis with clinical indicators and treated the condition should be able to be coded. We have not been fought on this topic, yet...
Dana Walker, RN CDS
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, August 27, 2014 1:10 PM
To: Walker, Dana
Subject: [cdi_talk] Coding Guidelines
Can anyone tell me where (if any place) in the guidelines it states that in order for a code to be coded/billed, it must be listed in the Discharge Summary? We are receiving managed care denials/rejections for codes that are coded but not mentioned in DC Summary. This sometimes happens when a condition in present early in the stay but resolves and is not mentioned in DC Summary. The ACDIS Boot Camp training earlier this spring indicated that "guidelines say a code only has to be documented one time if supported by clinical indicators. Being in the discharge summary is not a requirement but different organizations are making up their own rules (such as RAC)".
I found a coding clinical first qtr 2004 that indicates:
Question: Please provide clarification regarding the appropriateness of code assignments based on the documentation in the medical record by a physician other than the attending physician. Previously published Coding Clinic advice has allowed using documentation from the anesthesia report. Our coders have interpreted that the lack of contrary documentation from the attending can be perceived as concurrence with the anesthesiologist. We have recently been advised that we cannot use a consultant's note without "confirmation" from the attending physician. Our coders tell us that it is operationally impossible to confirm every single diagnosis or condition that the consultant writes. Of course, if there is conflicting information, we will query the attending physician for clarification. Can you comment on whether our interpretation of coding instructions is correct?
Answer: "Code assignment may be based on other physician (i.e., consultants, residents, anesthesiologist, etc.) documentation as long as there is no conflicting information from the attending physician. Medical record documentation from any physician involved in the care and treatment of the patient, including documentation by consulting physicians, is appropriate for the basis of code assignment. A physician query is not necessary if a physician involved in the care and treatment of the patient, including consulting physicians, has documented a diagnosis and there is no conflicting documentation from another physician. If documentation from different physicians conflicts, seek clarification from the attending physician, as he or she is ultimately responsible for the final diagnosis. This information is consistent with the American Health Information Management Association's (AHIMA) documentation guidelines."
This CC seems to indicate to me that if a consultant documented a Dx in a progress note but the attending did not place it in the DC Summary it would still be okay to code it as long as there were no conflicting diagnoses between the 2 physicians. Any thoughts????
DISCLAIMER: The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for use by the intended recipient. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. The partaking of any action in reliance upon this information by persons or entities other than the intended recipient is illegal and a violation of the regulatory guidance in the Health Insurance Portability and Accountability Act (HIPAA). If you received this in error, please contact the sender immediately and delete the material from all computers.
___________________
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, August 27, 2014 12:46 PM
To: Hoffmeister, Loretta
Subject: RE:[cdi_talk] Coding Guidelines
We have received some denials of this nature at our facility and had to go to the Office of Administrative Courts to defend.
[Description: signatureMegBuyrn]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, August 27, 2014 3:55 PM
To: Hoffmeister, Loretta
Subject: RE:[cdi_talk] Coding Guidelines
I found this coding clinic 2nd Q 2000 Page: 17 to 18 effective with discharges: July 1, 2000.
Question:
I am requesting clarification of what appears to be conflicting direction between an AHIMA Practice Brief and the Official Coding Guidelines. The AHIMA Practice Brief on Data Quality states that coding professionals may "assign and report codes, without physician consultation, to diagnoses and procedures not stated in the physician's final diagnosis only if these diagnoses and procedures are specifically documented by the physician in the body of the medical record and this documentation is clear and consistent."
The Official Coding Guidelines ODX #2 states "When the physician has documented what appears to be a current diagnosis in the body of the record, but has not included the diagnosis in the final diagnostic statement, the physician should be asked whether the diagnosis should be added."
Answer:
The two statements listed above are not inconsistent, but reinforce each other. When the documentation in the medical record is clear and consistent, coders may assign and report codes. If there is evidence of a diagnosis within the medical record, and the coder is uncertain whether it is a valid diagnosis because the documentation is incomplete, vague, or contradictory, it is the coder's responsibility to query the attending physician to determine if this diagnosis should be included in the final diagnostic statement. All diagnoses should be supported by physician documentation. Documentation is not limited to the face sheet, discharge summary, progress notes, history and physical, or other report designed to capture diagnostic information. This advice refers only to inpatient coding.
(c) Copyright 1984-2013, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.
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
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, January 29, 2016 11:06 AM
To: Kathryn Good
Subject: [cdi_talk] Coding Guidelines
Team,
I was taught to review all records including ER records. However, we do not code directly from the ER record. We use it as a tool to make sure that everything gets to the H&P that was initially documented. Some Inpatient CDI team members think they can code directly from the ER record. Please let me know your thoughts. I just want to follow the highest standard of practice on this.
Syndi Hudson, RN, CCDS,CCM
CHRISTUS Santa Rosa New Braunfels
CDI Specialist
cynthia.hudson@christushealth.org
830-643-6116 (Office)
830-643-5139 (Fax)
[CCDS_pin_1inch]
"We are His hands". Isaiah 64:8
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From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, January 29, 2016 1:06 PM
To: Debra L. Mullen
Subject: [cdi_talk] Coding Guidelines
Team,
I was taught to review all records including ER records. However, we do not code directly from the ER record. We use it as a tool to make sure that everything gets to the H&P that was initially documented. Some Inpatient CDI team members think they can code directly from the ER record. Please let me know your thoughts. I just want to follow the highest standard of practice on this.
Syndi Hudson, RN, CCDS,CCM
CHRISTUS Santa Rosa New Braunfels
CDI Specialist
cynthia.hudson@christushealth.org
830-643-6116 (Office)
830-643-5139 (Fax)
[CCDS_pin_1inch]
"We are His hands". Isaiah 64:8
achments.
Syndi Hudson, RN, CCDS,CCM
CHRISTUS Santa Rosa New Braunfels
CDI Specialist
cynthia.hudson@christushealth.org
830-643-6116 (Office)
830-643-5139 (Fax)
[CCDS_pin_1inch]
"We are His hands". Isaiah 64:8
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