Health Information Management

Tip: MLN Matters article stresses importance of complete record review

CDI Strategies, January 19, 2012

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MLN Matters article SE1121 emphasizes that coders must consider all documentation from licensed treating physicians and attending physicians when assigning a principal diagnosis. It states:

“The emergency room report, history and physical (H&P), and early progress notes may indicate the patient has one condition, but continuing workup and evaluation may determine something entirely different. By having access to the complete medical record, more accurate codes can be assigned.”
 
It also states that when “there is conflicting or contradictory information” in the record (e.g., sprained ankle and fracture), the attending physician should be queried for clarification.
 
The AHA’s Coding Clinic for ICD-9-CM, First Quarter 2004, pp. 18-19, encourages coders to assign codes based on attending physicians' documentation when a conflict exists and the CDI specialist or coder does not query the attending physician to resolve it. However, an attending physician's failure to mention a consultant's diagnosis does not mean there is a conflict, at least according to the MLN Matters article SE1121.
 
"A number of [audit] reviewers are taking the position that final diagnoses cannot be coded unless they're in the discharge summary," says James S. Kennedy, MD, CCS, managing director at FTI Consulting in Atlanta. "They're taking positions that unless the attending physician cites the consulting physician's diagnosis, the diagnosis cannot be coded. That is contrary to this advice."
 
Editor’s Note: The following tip is adapted from an article in the December 2011 Strategies for Health Care Compliance.



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