Q&A: Problem list use for principal diagnosis selection
Q: What considerations should coders keep in mind when referring to problem lists for determining the principal diagnosis and proper sequencing of all documented conditions in the inpatient setting?
A: Historically, problem lists were created to help providers document a patient’s chronic condition(s) that were often overlooked in later visits, such as chronic respiratory failure and chronic heart failure. A problem list is now considered to be an ongoing summary of a patient's current and past health issues. The focus of inpatient treatments will always remain the principal diagnosis, not the diagnosis listed first on a problem list, but because diagnoses on the list can be pulled from previous inpatient visits and listed randomly, these lists do not often align with the principal diagnosis.
Some coders may look at the list and say they cannot code from it while others may say that they can code for a diagnosis from the list if the diagnosis is still valid and currently being treated. But just because the diagnosis is listed on a problem list doesn't mean the provider actually addressed it during the present encounter either, leaving coders and CDI specialists to scrutinize diagnoses on the problem list to determine whether they are currently valid. This may require a query to the provider to clinically validate a diagnosis, rule out a diagnosis, or even rule in and garner greater specificity for a diagnosis.
Providers could also end up documenting something along the lines of “see previous day’s problem list” or “see previous day’s notes.” This may be acceptable for one day’s progress note, but if at any time treatment plans change or a diagnosis is not in subsequent progress notes (i.e., it was only documented once), the diagnosis may be subject to a denial based on the question of whether the diagnosis truly met the criteria of a diagnosis. Referring to prior documentation with such phrases does not meet compliance standards and may be considered fraudulent if ever reviewed by the Office of Inspector General.
The difficulty of using problem lists is further complicated when the list isn't updated, and it becomes difficult to tell which conditions are associated with each admission. It can also become very long as many of the listed diagnoses may no longer pertain to the patient. A patient's historical problem list may vary across encounters and should not be assumed to apply universally. It is the attending physician's or the attending provider's responsibility to determine and document which diagnoses are relevant to that current visit or current admission. If a recurring condition is still clinically valid for a current encounter, then the provider needs to document that the diagnosis is current and still being monitored, evaluated, and treated in each visit’s notes. Looking at a diagnosis from a previous record without current documentation or provider confirmation is inappropriate, which could lead to inaccurate coding.
An example of when coding becomes complicated by the problem list is when a patient's BMI is provided on the problem list instead of a diagnosis or a condition. Providers do this to try to avoid having terms in a patient's record that can be considered offensive such as obesity or morbid obesity, which flows into their patient portal. Some patients find this extremely insulting, and providers are sensitive to that situation. Yet, the practice of only using a BMI and not an associated diagnosis can lead to noncompliant reporting and coding.
Technology may help flag a diagnosis that lacks appropriate clinical indicators or diagnostic findings to support a diagnosis, and a review will be an essential component to ensure the diagnoses are clinically supported and coded. Let's say a patient is admitted for a fractured hip. They currently have pneumonia on the problem list, but since it isn't dated, it is unclear whether the pneumonia is current for the encounter. Then it turns out the patient was actually admitted for pneumonia three months prior. Current chest X-rays are clear, no antibiotics are being prescribed, and vital signs and labs are normal. It is determined the diagnosis of pneumonia that is on the problem list is not a valid diagnosis for this visit. If it is believed that documentation could lead to incorrect coding, a query should be sent for clinical validation and greater specificity. If a diagnosis is being monitored, evaluated, and treated, it can be captured as a codable diagnosis.
Editor’s note: This Q&A originally appeared in JustCoding and was answered by Lynette Byerly, BSN, RN, CCDS, CCS, a CDI education specialist with HCPro and ACDIS, on an episode of The ACDIS Podcast.