Principal DX in a discharge summary

edited December 2016 in Inpatient Coding
Sometimes an attending physician fails to add the diagnosis in the discharge summary that the coder has selected as the PDX. Of course we know best practice is to include all relevant diagnoses in the discharge summary. When the attending physician fails to include the PDX in the discharge summary, yet it's well documented throughout the chart, do you proceed with coding it as the PDX or do you require the physician to add this DX to the discharge summary by doing an addendum? We know that various auditors are requiring it and have gotten a couple of denials the past few years for this reason.

Karen Mathias, RHIA | Florida Hospital Waterman
Health Information Services, Director 352-253-3328


  • edited May 2016
    Unfortunately, that diagnosis and any others need to be a part of the DS even if it's well documented in the progress notes. Our auditors haven't tagged us on that, yet, but we know it's coming one of these years. In the meantime, we keep stressing to our residents and attending's the significance of having a complete DS.
  • edited May 2016
    Is there a regulation or standard that we can cite? Thanks
  • edited May 2016
    We query our physicians if there is a question about the principle
    diagnosis and it is not listed in the discharge summary. We then
    include the query as a permanent part of the record to support why we
    coded the chart the way we did.

    Paula DeFreece,CCS

    Credentialing Assistant

    Johnson County Hospital

    202 High Street, PO Box 599

    Tecumseh, NE 68450

    Phone: 402-335-3361

    Fax: 402-335-6342
  • Thank you for sharing this Karen! Has anyone else recently had a similar experience with documenting a PDX?
  • Not only have the discharge summaries  without PDX documentation been problematic with auditors and denials, but the MCC's  as well at my last two clients.  MCC has to be documented on the discharge summary, we had to check sodium levels for hyponatremia, creatinine for AKI to verify them.   Topping off these requirements, if the patient only suffered with one MCC--totally "problematic"--they need two or nothing. One MCC is a magic sign to audit and delay claims for insurance companies, RAQ and Medicare.    BSW|ContractCoder

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