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MRA Thought of the Day – One Time Diagnostic Statement

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Situation:

Lynn Salois, RHIT, CCS, CDIP, Director of Coding

Discharge diagnoses listed in the discharge summary are pneumonia and sepsis present on admission. The diagnostic statement of pneumonia is documented throughout the medical record. However, the diagnostic statement of sepsis is a one time diagnostic statement in the discharge summary only.

If in fact, both the pneumonia and sepsis were present on admission, coding guidelines dictate the sequencing of sepsis as principal diagnosis.

Would you assign sepsis as the principal diagnosis based on the one time diagnostic statement?

Here are my thoughts…

Clinically significant diagnostic statements and supporting clinical evidence should be consistently documented throughout the medical record to support code assignment. Code assignment based on a one time diagnostic statement creates a coding vulnerability in the auditor’s eye.

To avoid this compliance risk, re-educate CDS staff and physicians on the necessity of consistently documented diagnostic statements and supporting clinical evidence throughout the medical record source documents.

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