by Laurie L. Prescott, RN, MSN, CCDS,CDIP, CRC
Though many coders and auditors say so, there is no official direction that states diagnoses can only be reported if they’re included in the discharge summary. We teach in our CDI Boot Camps that, although it’s desirable if the discharge summary contains all diagnoses treated during the stay, coders can report diagnoses written anywhere within the record, including the ED record. Think of that patient who has an extended stay—conditions that were reported and documented within the first 24 hours that then resolve early may not be included in the discharge summary. That doesn’t mean they shouldn’t be reported.
That said there are a few things to consider.
The principal diagnosis must be documented by the attending provider and we teach that it must also be included in the discharge summary. It’s hard to defend the choice of principal diagnosis if was not included in the discharge summary.
Documentation by the ED physician can be reported, as long as it does not contradict the attending provider’s documentation. Conflicting documentation should always be clarified with a query.
A query should be placed if the ED physician states a significant diagnosis and it’s never mentioned in the record again. Query with the relevant clinical indicators to support this diagnosis and ask the attending if he or she agrees with the ED provider. Technically, we don’t have to do this, but if the diagnosis is one that will significantly affect the final coding, it should be followed through by the attending. Conversely, if the ED provider mentions a secondary diagnosis that is not as significant—perhaps a chronic condition or a diagnosis that provides less impact—and I see evaluation/treatment/monitoring provided, I would not necessarily query the attending for confirmation.
I suggest that each organization works together to decide when to report a diagnosis that isn’t mentioned in the discharge summary, or when a diagnosis can be reported based on the ED provider’s documentation. Openly discuss the guidelines related to reporting of diagnoses and work with your coders to define consistent organizational practices.
Editor’s note: Prescott is the CDI Education Director at HCPro in Middleton, Massachusetts. Contact her at firstname.lastname@example.org. For information regarding CDI Boot Camps, visit www.hcprobootcamps.com/courses/10040/overview.
Association of Clinical Documentation Improvement Specialists (ACDIS).
Article reprinted with permission.