The third reason that the discharge summary is more important than the H&P is that, given that the ICD-10-CM principal diagnosis establishes the foundation for the diagnosis-related group (DRG) essential to cost-efficiency measurement, we must be crystal clear what condition we determined (after study) to be the reason for which we wrote the inpatient order, how the diagnostic approach or treatment evolved, why the patient had an unexpectedly long length of stay, or why he or she consumed additional resources. If two or more reasons qualify, coders can pick a higher-weighted code if it is supported by the documentation. For more information on principal diagnosis selection, read this related article.
For example, a woman presents with pancreatitis, and the diagnostic workup determines that it is due to gallstones. In MS-DRGs, if the ICD-10-CM code for gallstones is sequenced as the principal diagnosis instead of the ICD-10-CM code for acute pancreatitis, almost double the resources are allocated to that admission. The coder, however, may not choose the gallstones as the principal diagnosis unless the discharge summary shows, beyond a shadow of a doubt, that the circumstances of admission, the diagnostic approach, and the treatment rendered support the gallstones as the principal diagnosis. This may require that we overtly document how the admission was not only to treat the patient’s acute pancreatitis, but also to determine its underlying cause. Under most circumstances, a cholecystectomy would be performed during that hospitalization; however, if the surgery is delayed, an overt discussion on the reason for the delay can help a coder understand why the gallstones could still qualify as a principal diagnosis, even without surgical treatment.
We have the same situation with atrial fibrillation and decompensated systolic or diastolic heart failure. Atrial fibrillation as a principal diagnosis is higher-weighted than heart failure when they coexist. Unless we discuss how the patient’s atrial fibrillation contributed to the patient’s decompensation and demonstrate that it influenced the diagnostic approach and treatment rendered (assuming it did), the coder may be less secure in sequencing atrial fibrillation as a principal diagnosis, however.
Last, but not least, the discharge summary is the only part of the inpatient medical record in which we may document uncertain, probable, likely, suspected, or still-to-be-ruled-out diagnoses, and from which a coder may code those diagnoses as though they existed. Physicians and coders cannot apply this rule on outpatient facility or physician claims. It is only allowed for inpatient facilities. Not only does this affect DRGs, it also factors into the hierarchical condition categories (HCC), and affects our cost efficiency under value-based purchasing and other CMS initiatives.
For example, the physician admits a due to chest pain. After a diagnostic workup, the physician determines the pain is noncardiac and discharges the patient home on a proton pump inhibitor. The DRGs for noncardiac chest pain are lower-weighted than those for heartburn or gastroesophageal reflux disease. Unless we state in our discharge summary that the chest pain was likely due to these conditions necessitating the use of the proton pump inhibitor, the coder must use chest pain as a final diagnosis. It doesn’t help to only state these clinically valid possibilities in the H&P, progress note, or consultation report; someone must clearly cite them in the discharge summary if they are to be reported.
In another example, a patient is admitted with pneumonia whereby all diagnostic studies are negative. Based on the definitive antibiotics prescribed, what organism does the treating physician think likely caused the patient’s pneumonia? If the patient received a full course of vancomycin, might the physician think the pneumonia was due to MRSA? The coder cannot code this thought, however, unless the physician puts it in the discharge summary.
Most HIM professionals agree that physicians procrastinate completing their discharge summaries. Physicians often delegate the task to individuals who may not have the proper insight into the patient’s condition, such as medical students, house staff, or nurses. These summaries often lack underlying causes, complicating factors, and consequences that affect resource utilization and severity of illness. They may not resolve conflicting information provided by various consultants. The result is a subpar summary, which in turn leads to poor data quality.
Editor’s note: To read part 3 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.