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Avoid the trap of probable diagnoses

Association of Clinical Documentation Improvement Specialists, November 5, 2008

ICD-9-CM official guidelines highlight the importance of discharge notes

Most inpatient coders are accustomed to seeing “probable,” “suspected,” “likely,” “questionable,” “possible,” “still to be ruled out,” or other similar terms in physician progress notes indicating uncertainty in physicians’ diagnoses. But if coders code these uncertain diagnoses without physicians bringing them forward in their final notes or discharge summaries, there could be trouble with recovery audit contractors (RAC) or other outside auditors.

“Just because a suspected diagnosis is documented in the [history and physical] doesn’t mean it still exists as an uncertain diagnosis at the time of discharge,” says Karen M. Lindemann, RHIT, CCS, CCS-P, CPC, case mix manager at a Maryland healthcare system. Coders sometimes develop a habit of coding uncertain diagnoses no matter where they are in the record, which is not compliant practice.

The ICD-9-CM Official Guidelines for Coding and Reporting is clear that providers must document any uncertain principal and additional diagnoses at the time of discharge:

If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” “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.

Remember that this rule applies only to inpatient admissions to short-term, acute, and long-term care, and psychiatric hospitals.

(To view the original reference, visit http://tinyurl.com/63q6tr and scroll to pp. 85 and 87.)

Remind and educate coders

Hospitals and coders should refamiliarize themselves with this language, Lindemann says. They must understand that if an uncertain diagnosis is not in the discharge note, they can’t code it. However, she adds, such doc-umentation will not be in the discharge summary all the time.

“This is especially important if the coder codes without a discharge summary,” says James S. Kennedy, MD, CCS, director of FTI Healthcare in Atlanta.

During his coding audits, Kennedy frequently reassigns DRGs because of new information in the discharge summary or because the physician did not include an uncertain diagnosis in the final note or discharge summary.

Coders can use clinical knowledge and judgment to determine whether it is appropriate to query for (but not to code) an uncertain diagnosis that the physician did not document on the discharge note, citing evidence in the medical record that the condition was not ruled out during the stay. In practice, however, physicians have most likely ruled out uncertain diagnoses that they do not carry through to the discharge note or ending progress notes, Kennedy says.

However, if physicians continue to document uncertain conditions throughout the progress notes, if there is evidence that the physician will work up the diagnosis, or if the patient requires further observation or treatment after discharge, the coder should query the physician.

Because a physician must provide clinical evidence that a condition is ongoing at the time of discharge, it’s safe practice to review all records for which coders have assigned codes based on uncertain diagnoses.

Encourage CDI specialists to be proactive

One way to combat this trap is to remind clinical documentation improvement (CDI) specialists to follow up with physicians who document uncertain diagnoses during the middle of patients’ stays, Lindemann says. For example, a CDI specialist could simply remind the physician to document the clinical significance of laboratory studies. Or the CDI specialist could ask the physician to write a statement explaining what conditions he or she ruled out upon discharge.

Reminding physicians to document appropriate uncertain diagnoses in the discharge notes is critical, Kennedy says. It relieves coders from conducting additional physician queries while coding discharged records.

Coders should do most of the querying before coding the record, Lindemann says. The coding department, CDI specialists, and compliance officer must communicate in order to alleviate this problem.

“Encourage everyone to review the guidelines,” says Kennedy. “Coders can fall into the trap because physicians and coders sometimes forget the rules.” Continue to audit your records regularly and beware of this risk area.

Of course, not all hospitals have an entire CDI team at their disposal and are only able to spot-check a small percentage of records. Do what you can with what you have to be proactive.

Avoid noncompliant coding with incomplete discharge summaries

Many coders face the pressure of coding records without the discharge note or summary. Physicians typically have up to 30 days to complete their records, but hospitals want coders to code records as quickly as possible—frequently within four days of discharge. Best practice is to hold the record for coding until the physician completes his or her final documentation. However, some hospitals and physicians are lax in enforcing chart completion timeliness.

Coding managers should emphasize to their facility’s chief financial officers that timely chart completion is integral to good patient care and staying compliant with the Medicare Conditions of Participation and The Joint Commission’s (formerly JCAHO) accreditation standards, explains Kennedy. Ideally, the physician should perform the discharge summary within 14 days (seven in California) to allow for typing, correcting, and signing within the 30-day deadline. “Recent reports of the success of the RAC program should encourage attention to this issue,” he adds.

Medicare announced July 11 that it collected $697 million’s worth of hospital billing mistakes in three years, paying RACs $187 million to carry out their reviews. This 5:1 return on investment supports the nationwide RAC expansion set for completion in 2009, Kennedy says.

“Take whatever steps are necessary to make sure there is enough clinical evidence and documentation to support the diagnosis,” Lindemann says. Physician queries and strict adherence to official rules remain the best ways to protect yourself and your facility from a RAC audit.

Editor’s note: To read the entire RAC report, go to http://tinyurl.com/58lja2.

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