Q&A: Who’s responsible for deciding which secondary diagnoses appears on a claim?

Q: Is it a coder’s responsibility to properly sequence secondary diagnoses or is this a process that happens when the codes are transferred to the super bill? My concern is with making sure that heavily weighted secondary diagnoses which affect severity of illness (SOI)/risk of mortality (ROM) and hierarchical condition categories (HCCs) are not making it to the bill, which could result in reduction of risk adjustment and quality stratification for our health system. What is considered “industry norm” for this process?

A: This is a great question, and demonstrates your understanding of how important the sequencing of secondary diagnoses can be. Many CDI professionals struggle with this concept. This practice could be very important if you have a patient for whom the coder “triages” diagnoses when they cannot report all those that are available. Do the coders know how to prioritize secondary diagnoses to not only maximize DRG payment (CC/MCC capture) but severity of illness/risk of mortality and assist with quality measure reporting (risk adjustment considerations and exclusions)? 

You are correct that we cannot submit more than 25 secondary diagnoses on a Medicare claim, so we do want to ensure the important ones are listed and billed for appropriately.

In my experience, this process is left up to the coding staff and perhaps the software they use to group would also assist in sequencing considerations. Due to the importance of this issue, it may very well be a shared function at some facilities and could warrant a cross-disciplinary conversation. The conversation should include members of your quality department, CDI, and coding staff.

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.