ED secondary diagnoses

Can you take a secondary diagnosis from the ED documentation (as long as there is no conflict)or query a diagnosis from the ED documentation. I have heard conflicting ideas on this. We have a new CDI department and would appreciate guidance.

Comments

  • Yes...see references.


    VOLUME 29 THIRD QUARTER

    NUMBER 3 2012, Page 22



    Emergency Department Physician’s Documentation of Respiratory Failure



    Question: The patient presented to the Emergency Department (ED) in full cardiac arrest and respiratory failure due to an acute myocardial infarction. He was resuscitated, transtracheally intubated and placed on mechanical ventilation. The patient was admitted to the intensive care unit and after a short period he expired. The ED physician documented acute respiratory failure. However, the attending physician did not document acute respiratory failure in the health record. Is acute respiratory failure a codeable secondary diagnosis based on the ED physician’s documentation of this condition?



    Answer: Yes, code 518.81, Acute respiratory failure, should be assigned based on the ED physician’s diagnosis, as long as there is no other conflicting information in the health record. Whenever there is any question as to whether acute respiratory failure is a valid diagnosis, query the provider.





    Coding advice or code assignments contained in this issue effective with discharges September 15, 2012

    CC 2000 2nd Qtr

    Question:
    A diagnosis of COPD on an anesthesia evaluation is signed by the anesthesiologist. No other medical record documentation exists stating COPD for this patient. Should COPD be reflected by the attending physician in the body of the record such as the history and physical to be codable?

    Answer:
    It would be appropriate to assign code 496, Chronic airway obstruction, not elsewhere classified, for the COPD. Coding is based on physician documentation. The anesthesiologist is a physician. However, if there is conflicting information in the record, query the attending physician for clarification. Refer to Coding Clinic Second Quarter 1992, pages 16-17 for a previous example of COPD documented in the history section of the medical record. If there is evidence of a diagnosis within the medical record, and the coder is uncertain whether it is a valid diagnosis, it is the coder's responsibility to query the physician to determine if this diagnosis should be included in the final diagnostic statement. Evidence of documentation is not limited to the face sheet, discharge summary, or history and physical.

    CC 2000 2nd Qtr


    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.

    CC 2000 2nd Qtr

    Clarification, Reporting Of Chronic Conditions

    Recently, the Central Office has received multiple letters requesting clarification regarding whether chronic conditions such as hypertension, congestive heart failure, asthma, emphysema, COPD, Parkinson's disease, and diabetes mellitus are always reportable.

    Chronic conditions such as, but not limited to, hypertension, congestive heart failure, asthma, emphysema, COPD, Parkinson's disease, and diabetes mellitus are reportable. The Uniform Hospital Discharge Data Set (UHDDS) defines "Other Diagnoses" as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses which relate to an earlier episode which have no bearing on the current hospital stay are to be excluded."

    For reporting purposes, chronic conditions need to meet the UHDDS definition of "other diagnoses." According to the Official Guidelines for Coding and Reporting:

    For reporting purposes the definition for "Other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring:

    Clinical evaluation; or
    Therapeutic treatment; or
    Diagnostic procedures; or
    Extended length of hospital stay; or
    Increased nursing care and/or monitoring

    This is consistent with information previously published in Coding Clinic Second Quarter 1992, pages 16-17; Second Quarter 1990, pages 12-13; and July-August 1985, page 10.



    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.412.9421

  • YOU can capture any diagnosis from ED as part of an inpatient stay, and so not as conflicting. If its conflicting you need to clarify as ruled out, resolved or still active.

    Juli

  • The biggest issue I personally have when either coding or working as CDI is that relevant diagnoses, such as acute respiratory failure, acidosis, and so forth, are present and treated in the ED, but not consistently stated in a manner that makes it clear one should code the condition.

    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.412.9421

  • I agree. Also many dx are 'differential' dx in the ED. My thinking is that this makes them suspected/possible dx and therefore require confirmation as possible/probably/confirmed dx.

    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


  • edited April 2016
    I agree with you Paul.
    I was trained by a wonderful coder with many years of experience and she cautioned us on using ED diagnoses without clarification from the attending. I always remember her saying, "just because the patient presents to the ED with acute respiratory failure, does not mean you can code it without review of clinical indicators and collaboration from the attending."

    Most often there is agreement but every once in a while we have to obtain clarification.
    Lisa




    Lisa Romanello, RN,BSN,FNS,CCDS
    Manager, Clinical Documentation Improvement
    Quality and Compliance
    CJW Medical Center
    Office phone: 804-228-6527
    Cell phone: 804-629-0396
    AHIMA Approved ICD-10 CM/PCS Trainer
    Angelisa.Romanello@HCAHealthcare.com




  • But what if they have indicators that support resp failure in ED-but by the time the attending or h&p is done, that has resolved? Many times our H&P says, "currently/ now/ at the time of my review, not in resp distress". That shouldn’t preclude you from capturing a diagnosis from ED so long as they meet criteria related to the diagnosis. Our consultant group has consistently educated us not to negate these diagnosis just because that issue resolved in ED.

    Juli

  • If indicators for any condition are met and no 'dissonance' charted, condition should be coded...the problem may arise if the same condition is referred to by multiple clinicians with different clinical terms that are assigned different codes.


    REQUEST FOR CLARIFICATION – CONFIRM OR RULE OUT



    The diagnosis of (diagnosis) was documented on (Date), but is not consistently noted in subsequent documentation

    PLEASE CLARIFY THE FOLLOWING:

    • The above diagnosis was present on admission and is now resolved
    • The above diagnosis was present on admission and is still being monitored, evaluated, or treated
    • The above diagnosis was ruled out
    • The above diagnosis is still a likely, suspected, probable diagnosis
    • Other:

    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.412.9421

  • Thank you so much for the advice. I really like the Request for Clarification query and will use it.

    Donna Butler, RN, BSN, CDS
  • Paul,

    I know this thread is old but I am reviewing/auditing some CDS clarification from multiple facilities and I am coming across validation clarification, mostly with the diagnosis of "pneumonia." The are addressed to the attending physician and they are asking if they concur with either a consultant or the ED provider. It appears to be secondary diagnosis and it does not conflict rather the absence in attending documentation. Is this due to this statement in the  guidelines "The following guidelines are to be applied in designating "other diagnoses" when neither the Alphabetic Index nor the Tabular List in ICD-10-CM provide direction. The listing of the diagnoses in the patient record is the responsibility of the attending provider." or is it a consequence of a conservative Coding Department?

    Thanks Kathy Beaute BSN RN CDS

  • Paul,

    I know this thread is old but I am reviewing/auditing some CDS clarification from multiple facilities and I am coming across validation clarification, mostly with the diagnosis of "pneumonia." The are addressed to the attending physician and they are asking if they concur with either a consultant or the ED provider. It appears to be secondary diagnosis and it does not conflict rather the absence in attending documentation. Is this due to this statement in the  guidelines "The following guidelines are to be applied in designating "other diagnoses" when neither the Alphabetic Index nor the Tabular List in ICD-10-CM provide direction. The listing of the diagnoses in the patient record is the responsibility of the attending provider." or is it a consequence of a conservative Coding Department?

    Thanks Kathy Beaute BSN RN CDS


    Hi Kathy,

    At my organization, we tend to send a validation queries if the diagnosis is at risk for denial, even if there is no conflict. I explain it to the providers like this: if you haven't said it, I don't want to assume whether you ruled it out or resolved it, so I'm going to ask. Hope that helps.

    Whitney Garcia, MSN, RN, CCDS, CCS, CRC
    Whitney.Garcia@asante.org

  • Thank you Whitney
  • If ‘pneumonia’ is ONLY documented by the ED MD and is not further stated, I’d also issue a query.  

    I view this as ‘different’ than something such as hyponatremia or even acute respiratory failure which can be present, treated in the ED and may be resolved prior to time the patient is seen by the Attending.  

    So long as such conditions are present with supporting clinical evidence and are documented in the ED, there is a ‘coding rule’ that supports the thought they can be coded ‘as long as there is no “dissonance”.   So, we have to consider the situation and apply critical skills for each particular situation.

    In my view,  pneumonia, MI, Sepsis, to name a few are often listed as Potential Conditions early on during the encounter, and often may be either ruled in or ruled out.

    I hope this is useful?

    Paul Evans, RHIA, CCDS
  • ED MD documents hyponatremia and sodium is 124 - repeat lab testing in ED confirms sodium levels, and fluid restriction ordered.  Hyponatremia is coded.

    ED MD documents “pneumonia’.  No other clinician documents pneumonia, rather, acute bronchitis, only, is documented per H&P, progress notes.  Pneumonia may NOT be coded on the basis of the ED visit.

    Is this helpful?

    Pe
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