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Updated on: November 28, 2016

Problematic Diagnoses

Original story posted on: March 14, 2016

As I was listening to a recent broadcast of Monitor Mondays, I was a bit taken aback when I thought I heard the phrase “the physician writes down the diagnosis, and it should be accepted as the diagnosis.”

So now I will explain why when the physician writes down the diagnosis, it may not be the diagnosis. Physicians see numerous patients per day either in the hospital, clinic, or office setting (or sometimes in all locations). They often don’t have time to take a lunch – and if they do, and you ask them what they had for lunch, seldom will they remember. So how do you expect them to remember all the patients and all the clinical conditions each patient is exhibiting? Did you ever think that the provider might be mistaking Mrs. Jones’s chart for Mrs. Smith’s and documenting the wrong diagnosis? It probably doesn’t happen often, but the  possibility exists.

For inpatient service, the entire length of stay is a story, with a beginning (either represented as an ED visit or an H&P), a middle (with progress notes and consults and surgical notes, if any), and an end (represented by a discharge summary). In simple terms, if I am reading a book about apple-picking, then the entire book should reference apples. If somewhere in the middle of my story all of a sudden I see reference to an orange but there is no introduction about the orange, no other mention of the orange throughout the story, and no reference to the orange at the end, or any indication of why the orange was important to the story, then I am left pondering what the orange had to do with anything. It is not a mystery, and therefore not a red herring (for those of you that read mysteries, you will understand that a red herring is something thrown in to have the reader arrive at a wrong conclusion or thrown off track, as in an Agatha Christie whodunit, for example).

Bringing the concept to healthcare, sometimes you encounter an entry in the chart for acute renal failure (ARF), but in reading the chart you wonder how the provider arrived at that diagnosis. Acute kidney injury/acute renal failure mean that the kidneys have suddenly stopped working. The kidneys remove waste products and help balance water and salt and other minerals (electrolytes) in the blood. When kidneys stop working, waste products, fluids, and electrolytes build up in the body.  Acute kidney injury has three main causes:

  1. A sudden, serious drop in blood flow to the kidneys
  2. Heavy blood loss, an injury, or a bad infection (sepsis), any of which can reduce blood flow to the kidneys
  3. Not enough fluid in the body (dehydration)

If the indication of the renal failure is dehydration, and in reading the chart there is nothing to indicate a decrease in the patient’s skin turgor, but yet the documentation notes moderate to severe dehydration (fluid loss of 5 percent of body weight is considered mild dehydration, 10 percent is moderate, and 15 percent or more is severe), then the next step would be to look at the input and output (I&O) documented in the nurses notes. The amount of urine produced over a period of hours may also be measured for quantity and quality of the amount of waste being excreted. When kidney tissue is injured, protein (a large molecule with a daily excretion of less than 30mg) and desirable substances may be inappropriately excreted in the urine. Sometimes there are no symptoms expressed by the patient, but instead of insufficient urine production, there may be urinary retention or water-electrolyte imbalance or fatigue. In the case of urinary retention, the amount of urine remaining in the bladder after urination will be measured by inserting a Foley catheter to drain the bladder. However, if in reading the documentation in the chart there is no indication of decreased urinary output, swelling due to fluid retention, nausea, fatigue, or or shortness of breath, shouldn’t the coder stop and question it, especially if the DRG is impacted?

When coding or auditing, each individual involved should be thinking about what tests were ordered to substantiate the diagnosis or what the provider was thinking in ordering the tests. From a lab perspective, the levels of urea (blood urea nitrogen, or BUN, and creatinine) are high in kidney failure. This is called azotemia. However, a patient with chronic renal failure may exhibit a high BUN and creatinine, and this is why it is imperative for the provider to indicate in the clinical documentation the patient’s baseline so that if the patient has acute or chronic renal failure, the acute condition can be additionally coded. Electrolyte levels in the blood may be abnormally high or low because of improper filtering. When the duration and severity of kidney failure are long/high, the red blood cell count may be low. This is called anemia. One can also look at the lab values for too much acid in blood and tissues. If the diagnosis is not certain after laboratory tests, an ultrasound of the kidneys and bladder may be performed to help reveal signs of specific causes of kidney failure. In some cases, tissue samples of the kidneys are taken (biopsy) to find the cause of the renal failure, as in the case of suspected acute tubular necrosis (ATN).

There must be clinical evidence along with laboratory evidence (if indicated) to back up all diagnoses in each chart. The reader cannot infer from a single line entry or just from lab values that someone is exhibiting a condition. Each condition must be verifiable. However, if a coder sees ARF as an entry in the chart and the documentation is vague, then the correct next step should be to issue a query to the provider. An outside auditor (non-physician auditor) cannot refute a confirmatory query that is well-documented.

Per American Health Information Management Association (AHIMA) Guidelines for Achieving a Compliant Query Practice, generation of a query should be considered when the health record documentation is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent, especially when considering diagnoses that are major comorbidities (MCCs) and comorbidities (CCs) (these are also important on their own as severity measures), which can affect DRG assignment. Also, per AHIMA, generation of a query should be considered when the health record documentation describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis. Per the American Hospital Association (AHA) Coding Clinic, the provider is ultimately responsible for the final diagnosis.

When I was in medical school, the first lesson I learned was to CYA, and therefore I pass this on to others to this day. When in doubt, issue a query for clarification; yes, you may have to wait before the final bill can be dropped, but this will avoid the appeal process, which might take a year or longer, and will get you your deserved reimbursement the first time the chart is billed.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Denise M. Nash, MD, CCS, CIM

Denise Nash, MD has more than 20 years of experience in the healthcare industry. In her last position, she served as senior vice president of compliance and education for MiraMed Global Services, and as such she handled all compliance and education needs, including working with external clients. Dr. Nash has worked for the Centers for Medicare & Medicaid Services (CMS) in hospital auditing and has expertise in negotiation and implementation of risk contracting for managed care plans. Dr. Nash is a consultant on coding/compliance audits at physician practices and hospitals, and has worked for insurance plans conducting second- and third-level appeals. Her past experience also included consulting for the Office of the Inspector General of New Hampshire in its Fraud and Abuse Division. Dr. Nash is a member of both the RACmonitor and the ICD10monitor editorial boards.

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