Health Information Technologies and Processes

Principal Diagnosis Missing on Discharge Summary

  • 1.  Principal Diagnosis Missing on Discharge Summary

    Posted 05-07-2019 15:37
    Does anyone have an internal coding guideline where if the Principal Diagnosis is not listed on the Discharge Summary that the coder sends a query or asks for an addendum?  The documentation on our Discharge Summaries are poor and we are concerned about what is going to the PCP. For best practices in record keeping we feel the Principal Diagnosis should be listed on the Discharge Summary.



    ------------------------------
    Cynthia Fisher
    Coding Manager
    Western Maryland Health System
    ------------------------------


  • 2.  RE: Principal Diagnosis Missing on Discharge Summary

    Posted 05-16-2019 16:42
    Hello

    From what I know the final DX or clinical impression is needed in the report to code the visit. Also there is a link between the providers codes used in there documentation from SNOMED and statistics ​used for various things nation wide.

    ------------------------------
    Monica Martin, CCA
    PFS Charge Specialist
    ------------------------------