Health Information Management

Special editions MLN articles highlight inpatient coding vulnerabilities and admit date issues

HIM-HIPAA Insider, July 5, 2011

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by Kimberly Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc.

CMS released two special edition MLN articles last week. One article, SE1121, highlights some of the inpatient coding vulnerabilities identified through the RAC program, although coders shouldn’t find anything surprising in the guidance. The other article, SE1117, explains the proper use of the admit date and “from/through” date fields on the UB04, per the NUBC guidelines.
In the coding article, CMS discusses a potential source for error if coders code without the complete medical record. Specific examples discussed were missing discharge summaries and operative reports. They also emphasized that all documentation in the medical record by licensed, treating physicians, not just the attending physician, must be considered when assigning the principal diagnosis. This, coupled with their emphasis on the entire record, gives the potential for conflict between the documentation of the attending physician and other consulting physicians.
In this article, CMS recommends that the coder query the attending physician to clarify the correct principal and secondary diagnoses if there is a conflict between the documentation of the attending and secondary physicians. However, they remind coders that the simple failure of the attending physician to mention a consultant’s diagnosis does not create a conflict. This confirms that if a consulting physician documents a secondary diagnosis and the attending fails to mention it in his or her notes, it is appropriate to code the secondary diagnosis without further querying the attending physician.
Read more on the MedicareMentor blog.

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