March 28, 2017 | | Comments 0
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Guest Post: Discharge summary critical to hospital data quality and pay-for-performance, part 1

James S. Kennedy

James S. Kennedy

Probably the most onerous duty physicians have is the preparation of the inpatient discharge summary, especially after a long or complicated hospital stay. To be frank, I hate doing discharge summaries. I’ll find every reason to put them off. If I look at the current medical records delinquency list, I’m not the only one who has DCSAS, or discharge summary avoidance syndrome (which, by the way, does not have a code in ICD-10-CM). I’m sure you know someone similarly afflicted.

Given my unfortunate condition, I force myself to promptly and completely perform my discharge summaries—and there’s no better motivation than the realization that CMS and other payers are moving us from fee-for-service to what they call a quality- or value-based reimbursement system, as described by HHS Secretary Sylvia Burwell last December in a post on the Health Affairs Blog. I believe that Dr. Tom Price, Donald Trump’s new HHS Secretary, shares the same agenda.

Our success with these inpatient quality and value measurements is largely predicated on how well, and how timely, we organize and assemble our discharge summaries. While the admitting history and physical (H&P) is crucial for good patient care and utilization review, in ICD-10-CM/PCS-based coding and quality measurement, the discharge summary is even more important.

Why is the discharge summary more important than the H&P? There are several reasons.

First and foremost, receiving physicians look to the discharge summary to understand what inpatient diagnoses and treatments the patient obtained. Physicians are now accountable for preventing readmissions; thus, a well-constructed discharge summary will guide physicians at a skilled nursing facility or an outpatient clinic in continuing that diagnostic or treatment plan and keeping the patient out of the acute-care hospital. As such, the summary should be completed on the day of discharge and contain all acute and pertinent chronic diagnoses addressed, treatments administered, and consequences anticipated so the receiving physician can quickly understand the patient’s condition.

Second, the discharge summary represents the hospital’s final diagnostic statement of what the physician believes caused the patient’s symptoms. This is essential to assigning complete and precise ICD-10-CM codes, which factor into severity and risk adjustment. Sadly, ICD-10-CM coders are not allowed to clinically interpret the record to assign codes—they can only use the words we write or dictate.

Unless we continue to document acute diagnoses and underlying causes as they are diagnosed (e.g., documenting when established, documenting to say whether the diagnosis is better or worse, and finally documenting in the discharge summary), the coder cannot confidently assign all the ICD-10-CM codes to describe how sick our patients are.

Editor’s note: To read part 2 of this article, come back to the blog next week! Kennedy is the president of CDIMD-Physician Champions in Nashville, Tennessee. This article was originally published in the Revenue Cycle Advisor. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board. 

 

 

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Filed Under: ACDISCDI ProfessionClinical Documentation ImprovementGrowing your programTip Tuesday

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Linnea Archibald About the Author: Linnea Archibald is the CDI editor for the Association of Clinical Documentation Improvement Specialists (ACDIS). In this role, she helps out with the website, blog, social media, newsletter, and the CDI Journal. If you have any questions, feel free to email her.

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