Note from the Associate Editorial Director: Coding from the discharge summary

By Melissa Varnavas

I recently received an email from ACDIS friend, and Chapter Advisory Board member, Molly Seibert on behalf of her colleague Kelli Newcom regarding whether it’s okay to use a diagnosis noted on a query form for coding purposes if it’s not captured in the discharge summary.

Like many areas of CDI, the question raises a number of potential concerns and lead us to discuss several areas of procedural best practices, so Seibert and Newcom graciously allowed me to share some of our conversation here with CDI Strategies readers.

First, while there are common recommendations regarding discharge summary construction, there is no rule that every diagnosis needs to be listed there. Some subscribe to the rule of three where the diagnosis should be mentioned as investigated, treated, and then resolved or that it continued to be treated at discharge before being coded. But really the rules, according to the Uniform Hospital Discharge Data Set and the Official Guidelines for Coding and Reporting state that in order to code a diagnosis the condition must affect patient care by requiring at least one of the following:

• Clinical evaluation
• Therapeutic treatment
• Diagnostic procedure
• An extended length of stay in the hospital
• Increased nursing care and/or monitoring

Of course, this leaves aside the question of clinical validation. For today’s CDI professionals, clinical validation reviews mean ensuring that the entire medical record includes not only documentation of the diagnosis but the supportive evidence for the condition as well. But let’s not digress too far. It’s the CDI and coding professionals’ duty to examine the entirety of the medical record to discern the patient’s story for their encounter.

Embedded in our friends’ inquiry is also the question of whether a query can be considered a part of the legal medical record. This represents a matter of hospital and CDI policy versus governmental expectation or coding regulation. Some believe that making queries part of the medical record creates an unnecessary liability and can open the facility to auditor vulnerabilities. Others believe that query forms/programs should be transparent and used to defend against Recovery Auditors, denials, and Office of the Inspector General scrutiny.

The ACDIS/AHIMA 2019 Guidelines for Achieving a Compliant Query Practice recommends facilities develop a query retention policy which “specif[ies] the completed query be a permanent part of the health record and the location. If [the query] is not considered a permanent part of the health record, it should be considered as part of the business record and retained for auditing, monitoring, and compliance. If the query is deemed to be part of the health record, it will be subject to health record retention guidelines which vary from state to state.”

Accepting a diagnosis noted on a query for coding purposes would similarly require hospital/CDI/HIM program policy development to ensure all parties understand the parameters of such a process and to ensure compliance.

More specifically, Seibert and Newcom’s question read: “If a query (which becomes a part of the legal medical record) is sent on or after discharge to clarify a diagnosis and the response is ‘agree’ but the discharge summary is not updated with queried diagnosis, can the coder ‘accept’ the updated diagnosis in the query form as the correct diagnosis?”

With this scenario, not only would the facility need a policy that states queries are kept as a permanent part of the medical record but also what would happen in the situation described.

Most programs, however, include a note on all queries asking the provider to respond to the query but to also make sure they carry the appropriate documentation over to their patient’s medical record to ensure the highest quality of information for that patient. For many programs, the whole point of CDI is to ensure the integrity (completeness) of the medical record.

As the Guidelines for Achieving a Compliant Query Practice states, “the focus of CDI professionals is to review the health record to ensure clear, high-quality clinical documentation [as] ambiguous documentation fails to reflect the provider’s intent, impacts the clinical scenario (e.g., complications, quality of care issues), the accuracy of code assignment, and the ability to assign a code.”

Having all the information within patient’s record and not in separate query forms that need to be discovered helps audit-proof the record and ensure the best care for that patient.

Finally, physicians may be fussy about answering queries about what they did or didn’t included in the discharge summary and may not respond to CDI efforts. For this scenario, if policies indicated the physician was supposed to respond within the medical record there may be a need to call in the physician advisor to intervene or there may be an opportunity to develop additional policies for those recalcitrant folks.

Again, the Guidelines for Achieving a Compliant Query Practice, strongly recommends CDI and HIM programs have an escalation policy in place. It states

The escalation process may include, but is not limited to, referral to a physician advisor, the chief medical officer, or other administrative personnel. The escalation process is not meant to direct or intimidate the recipient for a specific or particular response. This policy should clearly outline expectations of each individual involved in the process, including the expected time frames in which resolution or further escalation is expected.

While we had a lovely exchange and enjoyed reviewing different aspects of this unique scenario, we’re sure that other CDI professionals have other experiences, and perhaps other recommendations, too. That’s why it’s often good to post CDI conundrums to the ACDIS Forum. Members of the ACDIS Advisory Board and CDI Boot Camp instructors watch the Forum and often provide feedback to questions posted there, but there’s also tremendous value in the ready responses from your CDI colleagues across the country. Here’s a link to a tutorial on how to use the Forum if you’re not familiar with it.

And, of course, while I may not immediately know the answer to your question, we’re happy to do a little digging and try to find additional information and resources for you. That’s what being a member of ACDIS is all about—growing and learning from a helpful network of amazing colleagues.

Editor’s note: Varnavas is the associate editorial director for ACDIS. Contact her at mvarnavas@acdis.org.