Additional Diagnoses Should Be Documented and Coded If They Affect Patient Care in Terms Of

·  Principal diagnosis – condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital.

·  Additional diagnoses should be documented and coded if they affect patient care in terms of:

o  Clinical evaluation

o  Therapeutic treatment

o  Diagnostic procedures

o  Extended length of hospital stay

o  Increased nursing care and/or monitoring

·  Only physician and advanced practice provider documentation may be coded (except BMI and pressure ulcer stages).

·  Information from previous admissions cannot be coded unless the physician refers to it during the current admission. The medical record from each hospitalization must “stand alone.”

·  Diagnoses can be coded from physician documentation anywhere in the medical record except if they are uncertain diagnoses.

·  Uncertain diagnoses (“possible,” “probable,” “suspected,” “likely,” “questionable,” “still to be ruled out” or other similar terms) are coded only if documented at the time of discharge. They must be included in the discharge summary or in a progress notes on the same date of discharge.

·  Diagnoses that are “ruled out” are not coded.

·  Coders are not allowed to make assumptions. Only the physician’s exact terminology may be coded.

·  Every patient condition that affects your treatment decisions should be documented.

·  Every lab value that causes concern should be given a diagnosis. (Example: documentation of “low sodium,” etc., is not codable. Hyponatremia must be used.)

·  Every test or procedure ordered should have a corresponding diagnosis.

·  Results of tests, x-rays, echocardiogram, pathology reports, etc., must be documented by the physician treating the patient. They cannot be coded directly from the test results.

·  Every medication or treatment ordered should have a corresponding diagnosis.

·  Generally the more specific the diagnosis, the higher the SOI/ROM. Example: “acute diastolic heart failure” has higher SOI/ROM than “congestive heart failure.”

·  Document acuity. Note if the condition is acute, acute on chronic, or chronic.

·  Include the specific infecting organism if known.

·  If you gave antibiotics to cover both gram negative and gram positive organisms, and neither were ruled out, document it in the discharge summary. This is especially important if covering for possible gram negative pneumonia.

·  Note if the condition is present on admission. Hospital acquired conditions and complications of care do not affect SOI/ROM scores. (This is especially important when documenting pressure ulcers.)

·  In critically ill patients, address all the body systems impacted by the patient’s illness.

·  Document any causal relationships between diagnoses, i.e., diabetic neuropathy, pancytopenia due to chemotherapy, etc.

·  In your discharge summary, if you start your diagnostic statement with a symptom followed by two comparative/contrasting diagnoses, then the symptom becomes the principal diagnosis, usually putting it in a lower-weighted DRG. Example: “dyspnea due to pneumonia vs. COPD exacerbation” codes to DRG 204 - Respiratory signs & symptoms with a relative weight of 0.6472. If, instead, you just state the two contrasting diagnosis without the preceding symptom (i.e., “pneumonia vs. COPD exacerbation”), then either diagnosis can be chosen as principal with a relative weight of 1.2076.

·  If there is conflicting documentation, the attending physician has the final say.

Helpful tip by Dr. James Kennedy during education to providers on documentation issues using the MUSIC acronym. “When a patient presents to the hospital with a problem, we need to know 6 things about the diagnosis:

·  Manifestation: What Symptom is manifested (e.g. Chest Pain, Sepsis, Delirium)?

·  Underlying Disease: What is the UNDERLYING PATHOLOGY that causes the symptom?

·  Severity: How SEVERE was it (e.g. was the diabetes uncontrolled; is the hypertension malignant)?

·  Instigating or Precipitating Cause: What tipped the patient over from their usual state of health to a condition that they had to present for care?

·  Complications: what are the COMPLICATIONS that resulted from the Event?

·  Document the reason the patient admitted to the hospital as an INPATIENT (could not be sent home as an outpatient or treated in the observation unit) whereby you devoted most of your diagnostic and therapeutic energy.”