Understanding whose documentation can actually be used for inpatient coding purposes is often a source of confusion and controversy. Misunderstandings can result in noncompliance or lost revenue for the hospital.
CMS official coding guidelines permit only documentation by a “healthcare provider” who is further defined as “any qualified healthcare practitioner who is legally accountable for establishing the patient's diagnosis.” This implies licensure or certification by a state agency and credentialing by the practitioner's organization (e.g., hospital medical staff). These requirements may vary state by state.
This definition of a health care provider may include physicians, osteopathic physicians, podiatrists, chiropractors, psychologists, advanced practice providers (such as nurse practitioners, physician assistants, nurse anesthetists), and residents and interns who meet the legal requirements. Medical students, nurses, nutritionists, physical therapists, respiratory therapists, social workers, and rehabilitation or occupational therapists are not included.
Two exceptions allow documentation of a condition by someone other than the health care provider: BMI and the stage of pressure ulcers. However, the health care provider must still document the presence and location of pressure ulcers, as well as a clinically relevant condition associated with an abnormal BMI.
In addition, for inpatient coding, the health care provider must be “directly involved” in the care of a patient. At a minimum, this requires speaking with and/or touching the patient while providing some sort of care. Therefore, medical reports such as imaging studies, laboratory or pathology reports, EKGs, echocardiograms, and exercise stress testing are not sufficient documentation. For inpatient coding, such reports must be specifically “interpreted” in the medical record by one of the patient's health care providers to serve as source documentation. Outpatient rules are somewhat different with respect to medical reports. If a health care provider performs an invasive procedure (e.g., interventional radiology or percutaneous cardiovascular studies), a procedural report is required and may be used as source documentation for coding.
Coders are instructed to use the entire medical record for a particular inpatient admission as the source for documentation; information contained only in a previous admission record is not used. CMS regulations specifically state, “Documentation is not limited to the face sheet, discharge summary, progress notes, history and physical, or other report designed to capture diagnostic information.” Some coders (and auditors) hold the mistaken impression that the discharge summary is definitive, or that information not included there cannot be used for code assignment.
Coders can and must use any and all source documentation contained in the medical record from all health care providers so long as it is clear, consistent and not conflicting. No health care provider's documentation takes precedence over another's; any health care provider's documentation is considered equally valid. If the patient is admitted from the emergency department, the emergency record becomes part of the inpatient record and is used for inpatient coding. Whenever there is conflicting information in the record, the attending physician is responsible for clarification and a final determination.