Health Information Management

Should coders wait for the discharge summary before coding?

HIM-HIPAA Insider, July 27, 2010

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A coder may delay sending a claim for many reasons, but should a missing discharge summary be one of them?

The answer is complicated because coders generally are held accountable to both the compliance and finance departments, says Kathy DeVault, RHIA, CCS, CCS-P, manager of professional practice resources at AHIMA in Chicago. If they hold the claim too long, they delay revenue coming in the door; however, if they submit it without first considering the discharge summary, they risk upcoding or downcoding, DeVault explains.
 
Information included in the discharge summary may not change the code assignment or resulting DRG, but when it does, the difference could be significant, says James S. Kennedy, MD, CCS, managing director at FTI Healthcare in Atlanta. It also could raise a red flag for an auditor looking for erroneous code assignment, Kennedy adds.
 
Note: To read more, visit the HCPro website. Subscribers to Briefings on Coding Compliance Strategies have access to this article in the July issue of their newsletters.



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