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As you know by now, RACs identify coding errors while performing DRG validation reviews, which focus on the hospital’s selection of principal and secondary diagnoses and procedures on a claim. They are discovering that far too many of these claims contain the wrong principal diagnoses. CMS explains what it sees as the source of the problem as follows.


Some hospital staff members assign codes to a claim before they even receive the complete medical record. (For example, discharge summaries or operative reports are often missing.) Since it is their responsibility to report codes that accurately reflect the patient’s conditions and procedures, assigning codes before receiving the complete medical record is a mistake.  About this practice, CMS states clearly, “Recovery Auditors will not take this into consideration.”


Although the business office may want to drop the bill as quickly as possible, it’s a mistake to do so when the goal is to capture the right diagnoses for the claims.  Specifically, the emergency room report, history and physical (H&P), and early progress notes may indicate the patient has one condition, but continuing workup and evaluation may determine something entirely different. More accurate codes can be assigned by having access to the complete medical record-which is exactly what RACs are reviewing.


Identifying Conflicting Diagnoses


When coding claims, if there is conflicting or contradictory information in the medical record, a coder should query the attending physician to clarify the correct principal and secondary diagnoses. About this, CMS paraphrases advice given in Coding Clinic, First Quarter 2004, as follows.


If there is conflicting physician documentation, and the coder fails to query the attending physician to resolve the conflict, hospitals are encouraged to code the attending physician’s version. However, the failure of the attending physician to mention a consultant’s diagnosis is not a conflict. (The emphasis is from CMS’s memo, so better pay attention!) So, if the consultant documents a diagnosis and the attending physician doesn’t mention it at all, it is acceptable to code it.


A conflict occurs when two physicians call the same condition two different things. For example, the attending physician documents a sprained ankle and the orthopedist refers to the same injury as a fracture.


Solid Clinical Proof


As with all codes, clinical evidence should be present in the medical record to support code assignment. The Uniform Hospital Discharge Data Set (UHDDS) guidelines for coding and reporting secondary diagnosis allow the reporting of any condition that is clinically evaluated, diagnostically tested for, therapeutically treated, or increases nursing care or the length of stay of the patient.


Principal diagnosis is defined in the UHDDS as the condition established after study to be chiefly responsible for occasioning the patient’s hospital admission. When determining it, all documentation by licensed, treating physicians in the medical record must be considered.


Answers to questions about ICD-9-CM coding guidelines can be found at: http://www.cdc.gov/nchs/data/icd9/icdguide09.pdf.  For SE1121, go to https://www.cms.gov/MLNMattersArticles/downloads/SE1121.pdf.


About the Author


Carol Spencer, RHIA, CHDA, CCS, is a senior consultant with Medical Learning, Inc. (MedLearn®) in St. Paul, Minn. She brings more than 20 years of experience in health information management, coding, teaching, data quality and revenue integrity. She is an accomplished local, regional, and national speaker and author covering topics such as recovery audit contractors (RACs), payment audits, MS-DRG reimbursement systems, ICD-9-CM coding, and is an AHIMA-approved ICD-10-CM/PCS Trainer. Ms. Spencer is a thought-leader in data analytics and an expert on compliance in coding, query, and clinical documentation improvement strategies.


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