Health Information Management

Q&A: Don't discharge the discharge summary

CDI Strategies, August 19, 2010

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Q: Should coders wait for the discharge summary before coding?

A: 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.

In some situations, waiting for the discharge summary is essential. For example, coders can only report uncertain diagnoses when they are included in the discharge summary, order, or note. The ICD-9-CM Official Guidelines for Coding and Reporting states:
 
If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. 
 
 In other instances, coders must determine case-by-case whether the discharge summary is necessary. The decision will depend primarily on hospital policy, clinical data specific to the case, and the coder’s comfort level and knowledge, says DeVault.



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