Coding, Classification & Reimbursement

1.  Inpatient coding - how much is too much??

Posted 02-22-2017 07:21
Per coding guidelines on reporting additional diagnoses in the inpatient setting, additional conditions are reported if they require clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring.

So...if a patient is given a medication during the inpatient admission, should there be a diagnosis for it?  What if these are considered their routine "home" meds??  What if it is given prophylacticly?

Is it appropriate to ask for the diagnosis related to the medication given for chronic conditions? 

The problem we are having is related to the difference in approach between CDI and coding in querying the physicians.  CDI is focusing on DRG and anything that affects SOI/ROM, which is understandable.  Coding is focused on a complete picture, and my question is, how complete do we want to be without sending endless queries? 

Any help would be greatly appreciated!!

Thanks!


------------------------------
Jody Hester, RHIT
Coding Supervisor
TLRMC
------------------------------


2.  RE: Inpatient coding - how much is too much??

Posted 30 days ago
Inpatients require an admission medication reconsideration (in the orders) which includes the indication (diagnosis) for the medication.  This is signed by the physician.   Code chronic conditions treated with medication from this document.


------------------------------
Julianna Perez
Manager, Medical Records
------------------------------



3.  RE: Inpatient coding - how much is too much??

Posted 25 days ago
Sorry for my late response!

Yes, we do have a med reconciliation, but it does not include the diagnoses for the meds that are given.

I do appreciate your help though.


------------------------------
Jody Hester, RHIT
Coding Supervisor
TLRMC
------------------------------



4.  RE: Inpatient coding - how much is too much??

Posted 11 days ago
I want to bump this back up.  Would you hold an inpatient chart to send a query for a diagnosis regarding home meds that are continued in the hospital?

Thanks!

------------------------------
Jody Hester, RHIT
Coding Supervisor
TLRMC
------------------------------



5.  RE: Inpatient coding - how much is too much??

Posted 10 days ago
Hello

I work in CDI and we would not query for the utilization of long term meds on a routine basis unless that long term med would support treatment for another condition. 

I think providers would become frustrated with endless queries and would begin to ignore other queries of greater importance. 

Not sure if I understood this question correctly, but that would be my opinion. I also dont think providers should have to link the meds to diagnosis. 

------------------------------
GregZobelgzobel@majorhospital.org
------------------------------