Coding a medical record with incomplete documentation jeopardizes coding accuracy and negatively impacts reimbursement. However, sometimes real world situations prohibit Coding Managers from adhering to best practice standards. In the following scenario the discharge summary provided clarifying documentation; leading to the right diagnosis and reimbursement.
A patient with a past medical history of lacunar infarct with residuals presents with facial weakness and leg weakness. Initial progress note indicates acute on chronic stroke. Additional progress notes indicate TIA versus new stroke or chronic stroke. Final progress note indicates lacunar infarct. Three notes, three coding options.
In this scenario the discharge summary was the most valuable source document. The discharge summary further clarified the workup, findings and principal diagnosis. After extensive work up, including a CT and MRA, there was no evidence of a new stroke. Therefore, a TIA was ruled in.
Here are my thoughts….
- If the discharge summary was not available at the time of coding, lacunar infarct would most likely have been assigned as the principal diagnosis, based on progress note documentation.
- A coding quality validation audit would identify a principal diagnosis change for this case, citing the discharge summary as the source document.
- Address untimely documentation issues with appropriate individuals at your hospital to ensure discharge summaries, operative reports, etc. are available at the time of coding.
- As your DNFB creeps up and hospital leadership asks if it’s possible to code a record without a discharge summary, tell them “yes”. But coding accuracy and hospital reimbursement could be in jeopardy.
What are your thoughts?