Health Information Management

News: MLN Matters article SE1028 rewrites rules of reporting secondary diagnoses

CDI Strategies, October 14, 2010

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A recent MLN Matters article has changed the official coding guidelines to define what documentation can be used for assigning secondary diagnoses, leaving some CDI specialists worried that it provides RACs with the ability to invalidate any diagnoses not specifically documented by the attending physician.

However, the good news is that the article has been brought to the attention of CMS and a corrected MLN Matters article may be forthcoming. ACDIS will monitor the situation.
 
MLN Matters article SE1028 (Recovery Audit Contractor (RAC) Demonstration High-Risk Diagnosis Related Group (DRG) Coding Vulnerabilities for Inpatient Hospitals) states that:
 
All inpatient admissions must have all ‘other’ or ‘secondary’ diagnoses identified by the attending physician.  Other or secondary diagnoses are additional conditions that affect patient care.”
 
However, this guidance directly contradicts Coding Clinic, which states that documentation can be taken from other providers participating in the care of the patient and does not have to be documented (or confirmed) by the attending physician. From Coding Clinic, First Quarter 2004:
 
“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…(if) there is no conflicting documentation from another physician (including the attending physician)”.
 
As of now SE1028 is still posted on the CMS Web site. You can read it here: http://www.cms.gov/MLNMattersArticles/downloads/SE1028.pdf.



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