Discharge Summary Documentation
Diagnoses in the medical record need to be documented on the discharge summary and documented elsewhere in the record with supporting clinical signs and symptoms. RACs in my experience have denied cases in which diagnoses either are documented only on the discharge summary or only in the medical record.
The ideal situation is to have the diagnoses in the medical record match those in the discharge summary. Unfortunately, many coders process accounts without the benefit of a discharge summary, as many are not available at the time of coding. Best practice would be to identify these accounts as priorities for deficiency management teams to reconcile the discharge summary with the coding staff for immediate validation of reported diagnoses and/or procedures. This practice would promote consistency and competency in final code assignment in conjunction with medical record documentation.
Case in Point
An example of missing documentation in the medical record when it is only listed on the discharge summary:
A patient was admitted with CHF. The patient’s discharge summary had an additional diagnosis for “exacerbation of COPD,” a complication/comorbidity (CC), but this was the only documentation for this diagnosis in the medical record. The patient did have symptoms of exacerbation of COPD documented, but not the terminology needed to code this diagnosis.
A concurrent physician query would have solved this problem, which now has turned into a retrospective physician query. The physician can be asked to add the diagnosis to a concluding progress note as a “late entry” in order for it to be supported for coding purposes. The initial MS-DRG is 293, with a relative weight (RW) of .6853. The potential MS-DRG would be 292, with a RW of 1.0302. The RW difference in this case is 0.3449. This would have had an impact on the hospital’s case mix index (CMI) and the facility’s reimbursement. If the facility had a base rate of $5,000, there would have been $1,724.50 left on the table due to lack of physician documentation in the medical record.
Emergency Room Physician Documentation
Several cases were identified in which an ER physician had documented diagnoses that were treated in the ER, but not added to the body of the medical record by the attending physician. These diagnoses can be coded provided they are not contradicted by the attending. Some of these diagnoses qualify as an acute condition present on admission; they possibly could have been assigned as the principal diagnosis if supported by the attending physician.
Take ER for Example
An example of ER physician documentation having an impact on the principal diagnosis:
The ER physician’s diagnosis on the ER record and admitting order was “syncopal episode complicated by anemia.” The H&P states that the patient’s hemoglobin was 8.0 and the patient was transfused one unit of PRBCs in the ER. Repeated labs were done on the hemoglobin throughout the admission.
There was no mention of the diagnosis for anemia anywhere in the medical record other than in the orders and in the ER record. If anemia was documented as an acute condition on admission by the attending physician, this would have been supported a potential principal diagnosis, which is a higher-weighted MS-DRG than that for syncope. This case would have benefited from a concurrent physician query. The initial MS-DRG for syncope is 312, with a RW of 0.7172.
The potential MS-DRG for anemia would be 812, with a RW of 0.7957. The RW difference in this case is 0.0785. This would have had an impact on the hospital’s case mix index (CMI) and the facility’s reimbursement. The anemia still can be coded as a secondary diagnosis because it meets the UHDDS guidelines for reporting additional diagnoses. A clinical documentation specialist could have queried the attending to support the diagnosis on admission.
Cardiology Conflicting Documentation Trends
There were several cases identified with conflicting documentation in which a cardiologist consultant would state the patient had a “NSTEMI” and the attending documents would state that the patient had “acute coronary syndrome (ACS).” When this happens, the attending physician needs to be queried to document which diagnosis was ruled in after study.
Acute myocardial infarction (AMI) and ACS sometimes are documented interchangeably, but they have two different code assignments. One is a major complication/comorbidity (MCC) code, and the other is a CC code. Both diagnoses also have two different MS-DRG assignments. The MS-DRG for the NSTEMI without a CC/MCC discharged alive is 282, with a RW of .08064. The MS-DRG with ACS as PDX would be 311, with a RW of 0.5070. The RW difference between these two diagnoses as PDX is 0.2994.
Another recent discovery was that some physicians now are using the term “demand ischemia” despite the fact that there is no specific code to cover this diagnosis other than an unspecified listing from the cardiac section of the ICD-9-CM coding book. After consulting with several physicians and showing them the code selections in the cardiology section of the coding book, they all have agreed that the code 411.89 (CC) for acute coronary insufficiency was the best choice to describe “demand ischemia.” Providing physician education has resolved this problem and now they are documenting appropriately.
A Symptom as Principal Diagnosis
When a symptom is documented followed by a condition versus another condition, the official coding guidelines state that the symptom must be designated as the principal diagnosis. Physicians should be instructed to document which of the other two conditions he or she felt had occasioned the admission to the hospital after study. An example would be a final diagnosis being “abdominal pain due to GERD versus gastric ulcer.” The abdominal pain would have to be designated as the PDX, which goes into MS-DRG 392 with a RW of 0.7173.The GERD MS-DRG is also 392. The gastric ulcer MS-DRG is 384, with a RW of 0.8326. The RW difference would be 0.1153. Educate physicians to avoid using the term “versus” followed by a symptom, and see if they can identify which condition they felt occasioned an admission to the hospital after study.
While abbreviations and symbols are a good way to expedite the documentation process, some symbols should not be used or documented as a diagnosis somewhere in the body of the medical record. The following are some common abbreviations that need to be documented as a diagnosis:
Doctors are expected to:
- Accurately record the severity of illness and the intensity of services.
- Identify all diagnoses that are present on admission.
- Comment on the significance of abnormal test results.
- Provide updates on the patient’s condition, including new, resolved or ruled-out diagnoses.
- Document all interventions performed and record their results.
It is best practice to keep track of documentation deficiencies and provide physicians with instructional seminars, utilizing case studies in your presentation. It only takes 10 minutes to give a presentation with a few documentation tips during the medical staff department’s specialty meetings.
About the Author
Mary Mills, RHIT, CCS is the president and CEO of Documentation Solutions, LLC, a corporate compliance consulting firm that implements clinical documentation improvement programs utilizing the talents of coders and nurses working together as a team in performing the concurrent medical record review process since 2001.
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