Q&A: What to do when the first-listed diagnosis changes each day
CDIP, CRC, answered this question.
Q: I was originally taught to do subjective, objective, assessment, and plan (SOAP) notes for a prior job with principal diagnosis listed first.
Do I need to intervene when providers change the first-listed diagnosis from day-to-day?
A: The progress notes are used for your provider’s evaluation and management (E/M) or professional fee (pro-fee) billing. They bill for every encounter (by day) they see the patient at the hospital. The fee can vary depending on the services provided, admission assessment, discharge plan, etc., and there are different levels of billing depending on how complicated the patient’s condition may be.
For pro-fee patient billing, providers are taught that the “first-listed diagnosis” should be the focus of the care for the specific encounter described in the note. This can vary each day. For example, a patient admitted with acute respiratory failure on day 1 and 2, may develop sepsis on day 4 and if the sepsis is the focus of care, it would be listed first. Or, for example, the respiratory failure is resolved and it may not even be mentioned on the daily progress note anymore.
The discharge summary of course should summarize the entire stay. The coding professionals review the entire record and all of the provider’s documentation to code an overall summary of the entire inpatient stay. Any diagnosis that meets the Uniform Hospital Discharge Data Set definition of a reportable condition should be coded. Of those conditions that are present on admission, the coding professional will sequence the one that occasioned the admission as the principal diagnosis. The principal diagnosis will be the one that determines the MS-DRG for billing.
There is a lot of regulatory guidance available to coding professionals that they must follow to correctly sequence the principal diagnosis. This guidance is found within the code set (conventions), Official Guidelines for Coding and Reporting, and the AHA Coding Clinics.
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CDI education director at HCPro in Middleton, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.