Physician "Impressions"

dfalen

Can we code from a physician's "Impression" on an H&P or should we only be going by "discharge" diagnosis from Discharge Summary?
RN's are wanting me to code the Impressions along with the discharge diagnosis.
I am very hesitant to code the Impressions if they don't show up in the discharge diagnosis listing.

SusanWinokur

CMS has the opinion that once the patient is ready for discharge, the final diagnosis has been determined. The final diagnosis (if not resolved) is what should be coded in home health. The only time symptoms should be coded is when the final diagnosis is still undetermined, OR symptoms are not related to a known condition, OR symptoms are not integral to a diagnosed condition.

Hospitals need to bill for tests and procedures before there is a final diagnosis. That is why they are allowed to code conditions that are suspected, possible, an impression and/or conditions to be ruled out. Read the documentation carefully. Was the physician impression written before a final diagnosis was determined, or is that the final diagnostic statement upon discharge? Once you know which way to interpret the documentation, follow guidelines in selecting your codes.


Susan Winokur, HCS-D, BCHH-C | Southwest Medical
Part of OptumCare
Senior Medical Coder, Home Health

8655 South Eastern Avenue, Las Vegas, NV 89123 USA
T    +1 702-838-0644
Susan.Winokur@optum.com
smalv.com