Health Information Management

Q&A: Documentation in the discharge summary

CDI Strategies, June 24, 2010

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Q:I have a question about the discharge summary. When a physician documents a firm diagnosis (not probable or suspected) the day before discharge can it be coded as confirmed, or does it need to be documented on the last day/in the discharge summary?

A: As long as a diagnosis is documented in the record it can be coded. Discharge summary guidance only applies to suspected/probable diagnoses, for which the ICD-9-CM Official Guidelines for Coding and Reporting state the following:

"If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “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."
This does not prohibit, however, some Recovery Audit Contractors from violating ICD-9-CM rules and disallowing established diagnoses that are not in the discharge summary.  Some hospitals in San Francisco are dealing with these issues.  It’s a complete violation of ICD-9-CM; I’ve encouraged that their attorneys take corrective measures.
A good lawyer knows the law; the best knows the judge and the jury.
Editor's Note: James S. Kennedy, MD, CCS, managing director for FTI Healthcare and a member of the ACDIS advisory board answered this question.

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