Wiki Help with Hospitalist coding

[SarahEFox]

The hospital where my group of hospitalists practice just started on electronic records. This has allowed us to see several errors in their documentation. In a recent meeting with the head physician, we were trying to explain to him that we can not use diagnosis that a specialist is seeing his patients for. They (our hospitalist) are listing under their diagnosis and A&P every diagnosis that the patient has in order of severity, regardless of whether the hospitalist is still treating this condition or not. The hospitalist's dx may not come into play until the 5th or 6th listed dx.

He states that the hospital (facility) coders have to have this information on every one of their notes in order for the facility to bill properly?? It was our understanding that the hospitalist's first listed dx should be for what HE was treating the patient for that day and not necessarily the main reason the patient was admitted to the hospital for(as these are being treated by other MD's). He can then list the other dx's if he needs to based on their effect on HIS main dx.

Should our docs be listing the principle dx in order of severity on every note for the facility whether he is treating it or not? Or should the facility coders be going into the specialist's notes to get these? What might this do to us in an audit if our first listed documented dx does not match what we billed?

Thanks so much for your help.

Sarah

 

[bedforak1]

THe hospitalists should only be documenting diagnoses they are actively treating. Hope that helps.

 

[dlashua]

We ran into a similar issue when we started our Hospitalist program. At the end of the day the HIM (inpt) has to have every dx listed for their billing and it is important that the order not be changed as the severity of DX is a major factor in reimbursement. What I would suggest is that your provider(s) make it clear in their daily progress note what they are actively treating the patient for. For example, if the patient is hospitalized for a hip replacement and is being followed by the Ortho for that, those codes must be listed, however if the reason the hospitalist is seeing the patient is HTN & DM then that note should clearly state that is what the patient is being followed for those dx's should be listed as well. As long as it is clear what each provider is managing I think you will be ok.