NOTE: All in-article links open in a new tab.
Coding Other Physicians’ Diagnosis(es)
Published on
Wednesday, April 13, 2022
Did You Know?
Coding other physicians' diagnosis(es), including consultant’s documentation that were not included in the discharge summary, is permissible and not considered to be conflicting.
Why It Matters?
Hospitals are missing valuable clinical information that could identify an increased Severity of Illness (SOI), increased Risk of Mortality (ROM) and, possibly an increase in reimbursement, when another physician’s documentation of a diagnosis is not reported. You need to show how sick your patients really are.
What Can I Do?
Review the references below and discuss with management if you are coding only the diagnoses listed on the discharge summary.
Resources:
- Coding Clinic, 1ST Quarter 2014, page 11
- MMP Article July 1, 2011: MLN Matters – Number SE1121: Recover Audit Program DRG Coding Vulnerabilities for Inpatient Hospitals
- Medlearn Matters SE1121
Article Author: Anita Meyers, RHIT, CCS
Anita Meyers, RHIT, CCS, is an Inpatient Coding Professional at Medical Management Plus. Anita has over twenty-six years of experience in inpatient and outpatient coding including 17 years of work at AQAF reviewing inpatient and outpatient records from Alabama hospitals. In addition to reviewing records she was the team leader in Beneficiary Services where she participated in case review activities, received and processed beneficiary complaints and handled fee-for-service denials for home health, hospice and skilled nursing facility services. Prior to joining the MMP team, Anita left AQAF to become an inpatient contract coder and worked at various hospitals in central Alabama. In her current position, Anita is an integral part of the Inpatient Services at Medical Management Plus.
This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.
