Since the beginning of the Clinical Documentation Program in 1998 our goal has been to provide a Medical record that reflects the most accurate DRG assignment and compliance with CMS coding guidelines. ALL diagnosis, even those documented by Consultants, MUST be documented by the attending Physician in the body of the medical record. Without written acknowledgement of the diagnosis by the Attending Physician, clarification from a Coding Specialist or Clinical documentation RN becomes necessary.
ALL diagnoses need to be carried thru the hospital stay to resolution or stated as possible, probable, suspected, or R/O. The condition established after study chiefly responsible for occasioning the admission to the hospital is sequenced as PDX. NOTE: 2 or more conditions present on admission either may be sequenced first. Other chronic conditions, (secondary) diagnosis that exist @ the time of admission (ie: CHF, systolic vs diastolic rx. with appropriate meds), conditions that develop subsequently during hospital stay, affect treatment received or increase LOS need to be documented by the attending Physician. Remember: Coding specialists DO NOT code from lab results, x-rays or Path reports.
Documenting all pertinent diagnoses both acute and chronic have the potential to affect the DRG assignment, possible change in reimbursement and most importantly produce a Medical record that is compliant with all regulations and prevent denials. As always your cooperation is appreciated, and any question or concerns are welcome and can be addressed by the Coding Specialists or CDS RN at EXT. 5200
