From the Forum: Ensure work done in the ED is captured

Imagine this scenario: A patient comes into the emergency department (ED) with acute-on-chronic respiratory failure. Of course, the ED physicians work hard to stabilize the patient. Consequently, by the time the patient is admitted to the hospital and moved to an inpatient floor for their other conditions, their respiratory status has stabilized and the attending physician never documents the respiratory failure after admission.

The question arises, then, should acute-on-chronic respiratory failure be coded?  

CDI professionals often encounter this situation, especially when they don’t specifically review the ED record for inpatient stays.

“Coding Clinic states a coder should code the diagnoses listed by the ED physician ‘unless there is dissonance or doubt about the validity of the condition,’” said Paul Evans, RHIA, CCDS, CCS, CCS-P, manager of the regional CDI program for a large healthcare system in the San Francisco, California area, and a member of the ACDIS Advisory Board, in a recent ACDIS Forum discussion, citing AHA Coding Clinic, Third Quarter, 2012, p. 22.

“When I see the condition of acute respiratory failure listed only by the ED physician, I check to see if it meets our approved criteria for clinical confirmation. Given a physician in the ED may encounter and treat many conditions successfully prior to transfer, this is a common situation,” Evans said.

Though the situation may be common, some Forum participants said their inpatient coders insist they cannot code from the ED record.

“At our facility, the coders and CDI review the entire record including the ED report, but only assign codes based on the documentation done by providers after admission,” said Betty Bogda, RN, BSN, CCDS, a CDI specialist at Morris Hospital and Healthcare Centers in Morris, Illinois. “Our coders tell us they cannot code from the ED record. I never thought to challenge that.”

The risk with this situation, according to Evans, is that some conditions resolved in the ED would affect the patient’s MS-DRG assignment, and consequently the facility’s reimbursement and quality scores. “We all know patients can spend considerable time in the ED prior to bed assignment, allowing ample time for recognition and treatment,” he said.

“I would take a proactive stance and take this information to coding,” said Jeff Morris, RN, BSN, CCDS, the supervisor of CDI at the University of Southern Alabama Health System in Mobile, Alabama. “Many times patients present with acute conditions that are remedied in the ED and the facility should be getting credit for that.”

Though those diagnoses resolved in the ED should be captured and given their due credit, some external auditors may still question their validity and try to remove them from the claim, according to Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, the CDI education director at HCPro in Middleton, Massachusetts.

“A query should be placed if the ED physician states a significant diagnosis and it’s never mentioned in the record again,” she wrote in a recent article on the ACDIS Blog. “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 to the attending.”

Editor’s note: Advice given in this article was taken from a recent discussion thread on the ACDIS Forum. To learn more about participating in the Forum discussions, click here. To read a recent article from the CDI Journal about CDI reviewing ED records, click here.