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Understand which parts of the medical record coders can use

Association of Clinical Documentation Improvement Specialists, April 7, 2008

Some CDI specialists think that everything between the first and last page of a medical record is fair game when it comes to code assignment. But in most cases, physician entries are the only appropriate sources from which to garner diagnosis codes.

The discharge summary is the most reliable part of the medical record because it is the physician's final account of his or her patient care, says Lori S. McGuire, CCS, EMT, founder of Simply Coding in Nevada, OH. The discharge summary best supports a principal diagnosis that the physician must determine after study.

Although physicians technically have as many as 30 days to complete their medical records (14 days in California), many hospitals require coders to code inpatient records within four days of discharge, says James S. Kennedy, MD, CCS, director of FTI Healthcare in Brentwood, TN. When there is a quick turnaround time, coders should look at the physician's progress notes or operative reports for guidance, recognizing that the discharge summary may potentially include conflicting information.

When in doubt, coders should hold the record until the physician completes the discharge summary so that it does not conflict with the final coded Medicare Severity DRG, Kennedy says.

Avoiding certain areas of the record

There are several areas of the record that coders should not use when assigning a code. For example, coders should never code from a nurse's notes. However, notes that a nurse provides can assist coders who are looking for important clues that might lead to a particular diagnosis. If this information is missing from the physician's documentation, coders can query the physician regarding a condition that a nurse may have intimated.

"I've seen instances where a nurse's note documents a patient's pain complaint," McGuire says. "The nurse calls on a physician who then prescribes the necessary medication. Due to simple human error, this information never made it to the progress notes. But coders can use clues like this to query their physician."

Coding from a dietitian's notes

According to Coding Clinic, coders can extract body mass index (BMI) from a dietitian's note. An individual's BMI is a measure of his or her weight scaled according to height.

"It's important to stress that although coders can get BMI from a dietitian's note, they can't assume that the patient is obese or underweight," says Shannon E. McCall, RHIA, CCS, CPC, instructor for HCPro's -Certified Coder Boot Camp-Inpatient and Original versions. "For example, if the patient's BMI is 35, they can't say that he or she is morbidly obese and assign code 278.01."

Rather, documentation from the patient's physician should support the obesity code assignment. Equally important is the fact that some BMIs are considered complications or comorbidities (CC) for 2008. CMS classifies the following BMIs as CCs:

  • BMI less than 19 for an adult (code V85.0).
  • BMI over 40 for an adult (code V85.4).

BMI reported from a dietitian's documentation is beneficial for several reasons. First, dietitians are very good at documenting BMI because it's an integral part of their patient evaluation, McCall says. Second, extreme BMI may lead to a CC and therefore to a higher payment, she adds.

Coding from a consultant's documentation

According to the first quarter January 2004 Coding Clinic, coders may use a consulting physician's documentation to code a record, provided it does not conflict with another physician:

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.

To illustrate this point, McCall provides the following example: An attending physician documents asthma as the cause of a patient's dyspnea. The next day, a pulmonologist provides the same patient with a diagnosis of mild chronic obstructive pulmonary disease as the cause of dyspnea without mentioning asthma or documenting any exacerbations. However, despite this additional information, the attending physician sticks to the asthma diagnosis when writing up the discharge summary.

In this scenario, due to the conflicting diagnoses, the coder should query the attending physician to find out which disease process is appropriate, McCall says.

Coding from an anesthesiology report

Anesthesiologists are treating physicians. In 2000, Coding Clinic supported the coding of diagnoses that -anesthesiologists assign. The 2000 Coding Clinic, second quarter, p. 15, states:

Coding is based on physician documentation. The anesthesiologist is a physician. However, if there is conflicting information in the record, query the attending physician for clarification.

For this reason, coders can safely code from an anesthesiology report. As with coding from a consultant's documentation, the anesthesiologist's diagnosis must not conflict with another physician. If, for some reason, it does, coders should query the attending physician.

Coding from ancillary service records

Coding from ancillary service records is often a touchy subject, says McCall. For inpatients, the first quarter January 2004 Coding Clinic states that:

Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance.

"There can be a bone of contention here because technically, radiologists and pathologists are physicians," McCall says. "But the guidelines tell us we cannot code off of lab tests or radiology tests if the physician doesn't identify the clinical significance of the findings first."

The findings in a radiology report are open to interpretation, McCall says. For example, if a particular patient has an abdominal mass, the radiologist might document that the mass is consistent with an abdominal aortic aneurysm. Because the finding is not definitive, the mass could turn out to be something entirely different. Until a treating physician validates the radiologist's findings through his or her own medical decision-making process or another diagnostic procedure--and documents this information in the record-the coder cannot abstract a code from the radiology report.

Many radiology findings are incidental and do not qualify as additional diagnoses, says McCall. For example: A radiologist examines a patient's chest x-ray and includes "minimal effusion" in the findings. This may not be a significant finding, and therefore, a coder should not assign a code for this condition unless the physician documents that it has clinical significance.

However, an exception to this rule exists, explains McCall. If a physician documents that a patient has a hip fracture, and an x-ray later shows that there is a fracture of the lesser trochanter, it's acceptable to code the lesser trochanter fracture. This is allowable because the physician originally acknowledged some sort of fracture in the hip, and the x-ray simply identified the specific location of the fracture in the hip. On the other hand, if the physician had only documented "pain in the hip" upon admission, and the x-ray revealed a fracture, then the coder should query the physician, McCall says.

Laboratory tests are a different story. A lab technician generally conducts these tests and also runs a printed report of the results. Often, the tests have expected outcomes. For example, if a patient has orthopedic surgery and ends up with a low hematocrit or hemoglobin after his or her procedure, the coder cannot look at the lab test and assume the presence of a clinical diagnosis. A treating physician should document a drop in hematocrit, and that the patient has anemia (preferably describing its etiology, such as acute blood loss), in order for the coder to assign a code, Kennedy says.

Pathology tests are different because pathology requires a more specific type of analysis than radiology, McCall says. A January 2004 first quarter Coding Clinic guideline prevents coders from coding from pathology tests for inpatient admissions:

If the attending physician documented "breast mass" and the pathologist documented "carcinoma of the breast," this would be conflicting information requiring clarification from the attending physician.

On the other hand, coders may code from pathology reports for outpatient visits, according to CMS Transmittal AB-01-144 dated September 26, 2001. To view the transmittal, visit CMS' Web site at www.cms.hhs.gov/transmittals/downloads/AB01144.pdf.

Understanding the consequences of incorrect coding

From a compliance perspective, coding from improper parts of the medical record can lead to an incorrect DRG assignment, and therefore, incorrect reimbursement. If an auditor can determine whether a coder demonstrates a clear pattern of reckless disregard or intentional ignorance of coding principles, this may be cause for employee sanction, says James S. Kennedy, MD, CCS, director of FTI Healthcare in Brentwood, TN.

Even in a nonaudit situation, large numbers of higher yielding Medicare Severity DRGs (MS-DRG) raise a red flag. For example, if a particular facility reports several pneumonia cases, and more than 60% of them are supposedly higher weighted "complex" pneumonia cases, payers will take notice, says Kennedy.

Why? Consider the following scenario: A coder assigns a code for gram-negative bacteria directly from information gleaned from a lab test. A physician did not document gram-negative bacteria as the cause of the patient's pneumonia. Once the coder assigns the code, the case erroneously falls under MS-DRG 179, Respiratory infections and inflammations without CC/MCC, with a relative weight of 1.2754.

On the other hand, if the coder had correctly reported the pneumonia according to proper ICD-9-CM and Coding Clinic rules, it would fall under MS-DRG 195, Simple pneumonia and pleurisy without CC/MCC, with a relative weight of 0.8398.

So what can HIM departments do to monitor incorrect coding and ensure that coders pull information from appropriate parts of the medical record?

"Audit, audit, audit," says Lori S. McGuire, CCS, EMT, founder of Simply Coding in Nevada, OH. "Audits are not scary if they are done to help coders and hospitals."