atelectasis in post op chest procedures

kmcdiarm@nhs-healthlink.org

Hi All,

Here is something I struggle with a bit. When or what criteria do you use to pick up the diagnosis of atelectasis in post op chest procedures (lobectomy or wedge resections,etc).

I feel like I am often leaving this cc behind, and I am wondering how other reviewers handle this.

Unknown

I query the physician based on chest xray findings

Tracey

lsipos@monument.health

For us, many times "atelectasis" is often referred to in the H&P under "xray findings" with no more than a blurb by the physician.....I normally look to see if there is documentation elsewhere in the H&P-the body, assessment of theis diagnosis, as well as seeing if the physician orders Incentive sprirometry, ect. It also helps if there is continued documentation in the progress notes to know that they are truly considering this a diagnosis and not just an xray finding.

don.cdi.rn@gmail.com

We look for increased attention / consideration in the documentation; more than the "standard" pulmonary toilet which every pt with similar surgery receives; prolonged duration (might even extend a day) or use of supplementary O2.

For example, it seems every CABG/valve pt has actelectasis, but for most it really is not a significant finding & most of the standard level of attention/tx is more preventative. We don't code or query on these patients

Don

kmcdiarm@nhs-healthlink.org

Thank you, all, for your answers to my question. It helps support my review decisions.
Kathy

evanspx@sutterhealth.org

To further endorse Don's message, suggest we reference this in "Coding Clinic" as well.
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AHA Coding Clinic