Help
I have a scenario I need help with. Pt came in with pleural effuson, unknown etiology. No hx of CHF. Thoracentesis was done. Fluid was clear and straw colored. No WBC's. Final dx was "parapneumonic pleural effusion" and "community acquired pneumonia".
I am thinking it would go to pleural effusion but coder is taking it to pneumonia. No coding clinic reference has been found yet.
Any feedback would be helpful.
Thx
Karen
Karen McKaig, BSN, RN, CCM, CPUR, CCDS
Case Manager
Clinical Documentation Specialist
Baxter Regional Medical Center
Mountain Home, AR 72653
870-508-1499
kmckaig@baxterregional.org
I am thinking it would go to pleural effusion but coder is taking it to pneumonia. No coding clinic reference has been found yet.
Any feedback would be helpful.
Thx
Karen
Karen McKaig, BSN, RN, CCM, CPUR, CCDS
Case Manager
Clinical Documentation Specialist
Baxter Regional Medical Center
Mountain Home, AR 72653
870-508-1499
kmckaig@baxterregional.org