Revenue Cycle

Help ensure RAC-friendly inpatient coding: The importance of discharge notes

Recovery Auditor Report, February 5, 2009

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 RACs 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. (Note: Remember that this rule applies only to inpatient admissions to short-term, acute, and long-term care, and psychiatric hospitals.)
 
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 James S. Kennedy, MD, CCS, director of FTI Healthcare in Atlanta. 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.
 
“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: This article was excerpted from a November 5, 2008, article on the Association of Clinical Documentation Improvement Specialists (ACDIS) Web site.

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