Practice Management Alert

Remember, diagnoses can change during hospitalization.

A patient entering the hospital with one condition might not have the same diagnosis for the entire hospital stay. Medical practices need to have ICD-10 coding smarts so they can be ready when a patient’s diagnosis changes during a facility visit.

Fallout: Billing for your physician’s hospital services with an inaccurate or out-of-date diagnosis could lead to lost revenue or fraud charges for the practice.

So be sure everyone in the practice remembers that diagnoses can change in the hospital due to various reasons, including the following:

The physician may narrow down the patient’s problem. For example, a patient may be admitted with chest pain, and the physician may rule out myocardial infarction and decide the problem is actually gastrointestinal in nature.

The patient may develop other problems. The patient may be admitted for dehydration problems but may start having chest pains.

The patient may experience complications that lead his original complaint to worsen significantly.

The problem: You can’t wait for the hospital to send you medical records and hope to bill in a timely fashion. You could be waiting six weeks after the patient gets out of the hospital for any records. So it’s up to your physician to let you know if a patient’s diagnosis has changed. Ensure that you have access to your physician’s documentation via the electronic health records (EHR) or other system so you can bill for his services based on the notes.

In addition, you should educate your physicians, and let them know that just because the patient has been admitted with a particular diagnosis doesn’t mean they should bill for that diagnosis for each visit. They should check the diagnosis listed on the EHR or other charting tool for each visit because they could be addressing different conditions at each encounter.

Distinguish Admitting from Treating Dx

If your physician doesn’t admit the patient to the hospital, then chances are the diagnosis he treats won’t be the admitting diagnosis anyway.

For example: Your physician performed gall bladder surgery on the patient two months ago. Your physician wouldn’t know the patient was admitted for pneumonia, unless the admitting physician called the surgeon in to check on the surgery. So your physician would bill under the postoperative gall bladder diagnosis, not pneumonia.

Watch out: If you’re not billing with the most up-to-date diagnosis, you may not be able to justify a higher level of service. The patient may have been admitted with a simple problem and then developed complications, so a subsequent visit could have more complex medical decision-making. But you won’t be able to justify a higher level code unless you know all the diagnoses.

Your best bet is to stay in close touch with the physician during the patient’s hospital stay, and make sure your entire coding team has access to all of the patient’s records — not just the admitting or discharge notes. This way, you can read all of the charts to ensure that you’re assigning the right diagnosis code every time.