Donna you are 100% correct – that was be totally unethical and against all guidelines.
Karen Mathias, RHIA
Florida Hospital Waterman |Health Information Services, Director | 352-253-3328
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Donna, As a compliance auditor I felt compelled to dig a little to provide you a few resources. I hope this helps :)
A few points:
Therefore, any supporting documentation provided through AHIMA should suffice as "official". All certified HIM professionals are required to adhere to their Standards of Ethical Coding.
AHIMA Standards of ethical coding requires the coder to:
This would apply if the diagnoses listed by the provider are incomplete and do not accurately reflect the conditions treated during the IP encounter.
Providing/suggesting diagnosis codes to a provider to record on the discharge summary is leading and unethical (regardless if they are documented elsewhere in the record). It is the PROVIDER's responsibility to accurately and completely assign ALL diagnosis codes. As such, a query may be submitted which requests the provider to verify if any diagnoses were overlooked or omitted from the discharge summary and offer dates and locations in the health record as a reference.
Per AHIMA's practice brief:
"When coding for an inpatient hospital stay, the diagnostic and procedural information and the beneficiary's discharge status (as the hospital coded and reported on its claim) must match both the attending physician description and the information contained in the beneficiary's medical record. Please review the "ICD-9-CM Official Guidelines for Coding and Reporting" and the "Medicare Claims Processing Manual", Chapter 6 to ensure complete and accurate coding."
ICD 9 Guidelines: "Adherence to these ICD-9-CM guidelines when assigning diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Volumes 1-2) have been adopted under HIPAA for all healthcare settings."
"In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient's diagnosis"
Medicare Claims Processing Manual -Chapter 23 - Fee Schedule Administration and Coding Requirements
10.2 - Inpatient Claim Diagnosis Reporting
On inpatient claims providers must report the principal diagnosis. The principal diagnosis is the condition established after study to be chiefly responsible for the admission. Even though another diagnosis may be more severe than the principal diagnosis, the principal diagnosis, as defined above, is entered. Entering any other diagnosis may result in incorrect assignment of a Medicare Severity - Diagnosis Related Group (MS-DRG) and an incorrect payment to a hospital under PPS. See Chapter 25, Completing and Processing the Form CMS-1450 Data Set, for instructions about completing the claim.
Other diagnoses codes are required on inpatient claims and are used in determining the appropriate MS-DRG. The provider reports the full codes for up to twenty four additional conditions if they coexisted at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay.
Medicare Claims Processing Manual:
Centers for Medicare and Medicaid Services and the National Center for Health Statistics. "ICD-9-CM Official Guidelines for Coding and Reporting." Available online at:
AHIMA-Managing an Effective Query Process:
"Must the claim reflect the exact codes that are on the EHR record? Most of my physicians do not know the codes and cannot properly code according to rank order guidelines and/or coding specificity. We would be bringing every chart back to them if we had to code from the codes they have listed."
Your codes (on the claim) must reflect the exact DIAGNOSIS/ES that are supported by the clinical documentation of the provider. The provider is not required to select a code but a diagnosis.
CMS Documentation Guidelines state:
II. GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION
"basically over educated data entry staff".
We are NOT clinicians and it is not our role to question the providers' clinical opinion. We ARE however educated to understand pathology in order to know when there is a discrepancy in the record that needs to be clarified by the provider. We cannot suggest or lead, but provide them the conflicting information and ask for them to clarify. The objective is to teach providers the correct way to document their findings; educate them on documenting specificity, POA, making clinical associations when necessary, so that a query is not needed.
I understand your frustration; however, it is the provider's responsibility (legally and ethically) to correctly document the care that they provide. It is our job to interpret the most appropriate code based on their documentation. Respectfully, ----------------------------------------- Jeanne Matz -------------------------------------------