Health Information Management

Q&A: Coding based on a note dated after the discharge date

HIM-HIPAA Insider, August 30, 2011

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Q: Some of our physicians are uncomfortable making addendums to the discharge summary to include the pathological findings (e.g., malignancy). They believe it would be illegal to make an addendum to the discharge summary when the pathology report comes back after the patient is discharged. Instead, they dictate a Tumor Board Note that summarizes the patient's course of treatment and final pathological diagnosis. Our concern is that the Tumor Board Note is usually dated a few days after the patient is discharged.

When a condition meets reporting guidelines for the inpatient admission, is it appropriate to use documentation dated outside the inpatient admission for coding purposes? Are there specific laws or guidelines that prohibit coding from documentation dated outside the inpatient admission?
 
For example, a patient is discharged January 1 with a diagnosis of uterine mass. The pathology report comes back January 3 showing uterine cancer, and the physician documents a Tumor Board Note that states “uterine cancer” January 5. Can we assign a code for uterine cancer based on this Tumor Board Note?
 
A: You may report an ICD-9-CM code for uterine cancer if the Tumor Board Note:
  • Qualifies as a “cancer staging form” as outlined in Coding Clinic, Second Quarter, 2010, pp. 7–8
  • Is part of the permanent medical record for that encounter
  • Is signed by the attending (not a consulting) physician for that admission
Refer to the above Coding Clinic and your facility’s medical staff bylaws or HIM or coding policies and procedures for further clarification. If the scenario described above meets these requirements, report ICD-9-CM code 625.8 for the uterine mass and ICD-9-CM code 179 for the additional diagnosis of uterine cancer.
 
If the pathological report was present on the chart before final coding without a cancer staging form signed by the attending physician and there is no documentation in the record of its findings by any treating physician, then query the physician. Consider the following query:
 
According to Coding Clinic, Third Quarter, 2008, pp. 11–12 and the ICD-9-CM Official Guidelines for Coding and Reporting, we may not report and code abnormal findings on the pathology report unless the provider indicates their clinical significance. Now that the pathology report is available, if appropriate, could you please clarify the patient’s diagnoses in your documentation based on these findings?
 
The coder should include the findings or pathology report for the physician’s inspection with the query.
While this may be frustrating to many physicians, given that the final diagnosis established by the pathology report factors into the reason for admission and the follow-up care, physicians should be encouraged to reflect this diagnosis in their medical decision-making. Coders are faced with the same dilemma with electrocardiograms and radiology reports, even though they were interpreted by competent physicians.
 
Refer to Coding Clinic, Third Quarter, 1992, p. 7 for additional guidance.
 
Editor’s note: James S. Kennedy, MD, CCS, managing director of FTI Consulting in Atlanta and member of the advisory board for the Association for Clinical Documentation Improvement Specialists (ACDIS), and Sandra L. Sillman, RHIT, PAHM, DRG coordinator who performs inpatient coder and physician education at Henry Ford Hospital & Health Network, answered this question in the August 14 issue of JustCoding.



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