Wiki Who decides the discharge diagnosis?

[c7hill]

Medicare patient was adm with CHF and also treated for COPD. Pt did not meet criteria for admission based upon the COPD. Doctor lists CHF as the primary dx on the d/c summary. Facility coder assigns COPD as the primary dx because the COPD was treated during the admission. This chart has been pulled for audit by CMS based upon the COPD dx. Debate is taking place about who decides the primary d/c dx -- physician or coder. Any insight to this?

 

[kevbshields]

The physician is unlikely to know ICD-9-CM guidelines, which dictate (in part) which code might be selected as primary or principal.

The facility coders will have a different criteria than the physician coder. Check out your ICD-9-CM definition of primary (first-listed) diagnosis, which states that it is "the diagnosis, problem, or other reason for the encounter/visit shown in the medical record to be chiefly responsible for the services provided" on that date of service.

Although we are basing that decision off the physician record, simply choosing what the provider "listed first" does not meet the requirements ICD-9 expects in determining which code to list as primary.

Note that the instructions to the physician coder are not to select what the provider lists as first.

 

[c7hill]

Thank you for your reply. The concern is that the patient did not meet criteria to be admitted for the COPD, but did meet criteria for the CHF. Both conditions were treated. The concern is how the auditor might view the medical record when the primary d/c dx is listed as COPD (which did not meeting admission criteria) versus admitting dx (which did meet criteria) of CHF. The record was pull for audit because of the COPD dx.

 

[kevbshields]

This sounds like a medical necessity issue, which is hardly relative to coding. I seriously doubt that the pro fees for this case generated the problem. More than likely, the facility coder's decision on the Principal Diagnosis triggered the review.