Q&A: Coding diagnoses left out of the discharge summary

Q: According to Official Guidelines for Coding and Reporting, uncertain diagnoses should be documented at the time of discharge. If a consultant documents an uncertain diagnosis in the final or last progress note and no discharge summary or final progress note has been completed by the attending provider, can we code that uncertain diagnosis? Or should we query the attending physician or wait for the discharge summary?

A: This one is sort of a “loaded” hot topic. I’ll give you my opinion on the matter but note that this not an official stance.

There is no language in the Official Guidelines for Coding and Reporting that specifies that the diagnoses must be present within the discharge summary. A medical record must stand on its own and in its entirety, not subject to any single page or document or obvious typo being an exculpatory issue (although that is exactly what the auditors will argue). The record stands as a unified body of documentation and it isn’t always expected that every single note will have every single diagnosis. And, this includes the discharge summary.

For 20 plus years, we followed those Guidelines and were directed to take codes from even anesthesia notes and orders. It has always been the position of the American Hospital Association (AHA), CMS, and the National Center for Health Statistics (NCHS) that the coder should review and code the ENTIRE medical record, not just the discharge summary. Discharge summaries are notorious for being incomplete, inaccurate, and quite frequently missing at the time coding is done. In the past, up to 80% of records were coded without a discharge summary even being present. In current times, that number is much lower, but it still happens.

Not only that, discharge summaries are often dictated in advance of the actual discharge date and or several days after the discharge date. As such, the discharge summaries are not known to be real time documents recorded “at the time of discharge” per the Official Guidelines for Coding and Reporting. Progress notes written on the day of discharge are technically more reliable as the real-time documentation occurring “at the time of discharge,” and I know this as someone who as reviewed these records for precisely these issues since 1998.

Unofficially, it is much more complex than what I’ve laid out above. Auditors, commercial payers, and even some industry experts argue that diagnoses need to be in the discharge summary in order to be coded. We need to distinguish the Guidelines as a separate entity from best practice. There is no debate that having it in the discharge summary is best practice. Arguing that it MUST be in the discharge summary, however, violates the language within the Guidelines. We must follow/be allowed to follow the Guidelines without hindrance or the entire foundation of reporting falls apart.

Bear in mind, the Guidelines have not changed even though real-world practice has. What’s occurred over last five to 10 years is that aggressive auditors who either don’t understand or don’t follow the Guidelines correctly are issuing denials. The new “best practice audit defense guidelines” has in many people’s minds, replaced the Guidelines.

At the end of the day, you are going to have to work towards what is best at your facility, what works with your auditors, and what minimizes risk of denials and audit concerns within your organization.

If you are indeed witnessing denials for uncertain diagnoses not being placed into the discharge summary or encountering coders refusing to report those diagnoses, I would recommend you conduct physician education informing the doctors that the diagnoses not being carried into the discharge summary are in fact being denied. Show them the denials in formal and informal education sessions. Following that, I would appeal the denials as violations of the Official Guidelines for Coding and Reporting. Finally, I would begin to query for confirmation whenever diagnoses which are inconsistently documented are not in the discharge summary. I do recognize that these modifications are not in accordance with the Guidelines for reporting uncertain diagnoses at the time of discharge, but it may be required to deal with your auditors and commercial payers in the best interest of your facility.

Addendum: Please note that since I originally wrote this answer, I have received an answer from the AHA Coding Clinic noting the following definition of “at the time of discharge” as:

“The time of discharge implies the patient has been evaluated, treated, and is ready for discharge from the facility.”

This is worthy of some discussion. It’s noteworthy that the answer I received did not define “at the time of discharge” by a specific document within the medical record, but rather by the timing in relation to the episode of care.

This is consistent with all previous advice from the Guidelines and Coding Clinics which also do not state the documentation must be within the discharge summary. Answers from the AHA contain pre-set form language that the information contained within cannot be shared without express permission and I have requested permission to share the letter in its entirety.

Be that as it may, you should also realize that any answer you receive in the form of a letter from the AHA is in fact not “official advice” per the usual standard. Therefore, I encourage each and every one of you to write into Coding Clinic and ask the same question until they officially answer it with a Coding Clinic entry. Once they readdress the issue, this should help tremendously with recovery auditors defense.

Coding Clinic’s response won’t necessarily help with the stance commercial payers take on the issue, however, as they may not always be forced to follow official guidelines (even though following them is mandated as part of the language of HIPPA and, technically, not following guidelines is a violation of HIPPA.) Payers are allowed to get away with this, because they are permitted to stipulate the specific terms in their contracts with payers. You should also fight this battle with increased vigilance on paying attention as to what is agreed upon with your insurance contracts.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CRC, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.