Diagnostic conclusion statements don’t sufficiently capture the clinical context and medical necessity for inpatient admission. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, discusses the importance of clinical context and quality of clinical documentation in the medical record.
Does the DRG accurately depict the patient’s story? Does the length of stay and severity of illness correlate with what actually happened? Heather Taillon, RHIA, and Cheryl Collins, BS, RN, offer tips to selecting the correct principal diagnosis.
Q: Our facility has a question about how other hospitals address this scenario: Patient is discharged to home (discharge status code 01). No documentation exists in the medical record to support post-acute care. Several months later, our Medicare Administrative Contractor (MAC) notifies us that the patient indeed went to post-acute care after discharge. The MAC retracts our entire payment. We need to resubmit the claim with the correct discharge status code. We are reluctant to do so because nothing in the medical record supports the post-acute care provided. Are other hospitals amending the record? If so, which department is adding the amended note?