Q&A: Can you code diagnoses not included in the discharge summary?

Q: A consultant has advised us to code only diagnoses listed on the discharge summary. If the diagnosis is not on the discharge summary, the consultant instructed us to query the physician. How do other facilities handle these scenarios?

A: At Henry Ford Health Systems, we use the entire medical record as the source document for our coding. The Official ICD-9-CM Guidelines for Coding and Reporting state, “The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”

Faye Brown’s ICD-9-CM Coding Handbook for 2011, Chapter 4 (The Medical Record as a Source Document) reiterates this same guidance:

“The source document for coding and reporting diagnoses and procedures is the medical record. Although discharge diagnoses are usually recorded on the face sheet, a final progress note, or the discharge summary, further review of the medical record is needed to ensure complete and accurate coding.”

It’s critical for coders to review all pertinent operative reports, pathology reports, and other special reports because physicians sometimes fail to list operations and procedures on the face sheet (i.e., first page of the patient record), or they don’t provide sufficient detail on this summary page.

A discharge summary usually provides:

• The reason for admission
• Significant diagnostic findings
• Treatment
• The patient’s course in the hospital
• Follow-up plan
• Final diagnostic statement

Review the medical record further to determine whether conditions mentioned elsewhere in the body of the discharge summary meet the criteria for reportable diagnoses as defined in the Uniform Hospital Discharge Data Set, according to Faye Brown’s ICD-9-CM Coding Handbook for 2011.

The American Health Information Management Association’s (AHIMA) October 2, 2008 practice brief, Managing an Effective Query Process, states:

“A joint effort between the healthcare provider and the coding professional is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. …The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”

When querying physicians, do not frame questions in such a way that the physician could answer with a yes or no, or respond to the queries with a signature alone. Avoid multiple choice format queries and don’t include any indication regarding the financial impact of the physicians’ answers. Lastly, don’t pose queries that lead the physician to make any presumptions or present any new information.

Editor’s note: Sandra L. Sillman, RHIT, PAHM, of Henry Ford Hospital & Health Network, answered this question. At the time of this article's release, she was a DRG Coordinator who does inpatient coder and physician education.This answer was provided based on limited information submitted to JustCoding, where it was originally published. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.