Ischemic bowel? Help!
Help me! I somehow ended up in a battle with a coder. This has never happened to me before. I have a great relationship with our on-site coders and the coding manager is 100% supportive of our program. This coder is a new coder and she is working remotely so I have not met her.
I am responsible for reviewing death charts for SOI/ROM as well as appropriate DRG and a few other things. I provide feedback, do retrospective queries for improved documentation and coding clarification, etc. We don't always agree, but we work it out. In this particular case we had a youngish patient found down (unknown duration, outside) hypothermic, dehydrated, hypotensive. Shock is documented but specificity is not provided. He has a complex course. He's an alcoholic, etc. encephalopathic, you know the deal. He is being tube fed, at goal, no issues. He has thrombocytopenia, they do a HIT panel which is positive. The MD stops heparin and starts argatroban but is suspicious as to whether this is really HIT and thinks its a false positive and sends blood for additional testing.
He is slowly progressing, up walking, etc. On day 10 in the hospital he has an acute event. Abdominal distinction, vomits, intubated, etc. he has an ischemic bowel, they do an ex lap and try to salvage. The bowel is necrotic and he dies a day later after family decides to stop pressures. Cause of death is ischemic bowel. In the d/c summery the MD states that the ischemic bowel may have been caused by the HIT but that he is unable to determine this conclusively. He also states that the second panel for HIT was negative. He also attributes the shock as being due to hypothermia, dehydration and possible "urosepsis".
The origional draft coding had the ischemic bowel as the Pdx. My feedback was that I didn't think it s POA and therefore could not be Pdx. She said that the presenting symptoms were indicative of ischemic bowel. I said the typical symptoms of ischemic bowel are abd distention, vomiting, diarrhea, and then increased WBC, shock, ect. I see no indication that it was POA. I have gone round and round with her but she is adamant that this is correct.
Am I missing something here? Clinically, do you see how someone could have an ischemic bowel for 10 days with normal bowel sounds, a soft abdomen and tube feeds at goal? I seriously baffled and second guessing myself.
And from a coding standpoint, would any of you be comfortable linking his presenting symptoms with an ischemic bowel. She asked her "friend" to look at it and her friend who has been a coder for 25 years) said she is right. I'm confused....
And then from a professional standpoint, what would you do? Our coding manager is out of town this week but I called her last night. She wants me to talk to the Dr and have him sign a POA query (likely stating no, in my opinion). This ocder has made is very clear she is annoyed at me getting invoved and said she doesn't see the point an any further discussion. I feel like I am further degrading our working relationship by taking this futher. At the same time, I am responsible for the accuracy of the death charts and i dont feel right about just letting this go.
I'd appreciate any insight.
Thanks!
Katy
I am responsible for reviewing death charts for SOI/ROM as well as appropriate DRG and a few other things. I provide feedback, do retrospective queries for improved documentation and coding clarification, etc. We don't always agree, but we work it out. In this particular case we had a youngish patient found down (unknown duration, outside) hypothermic, dehydrated, hypotensive. Shock is documented but specificity is not provided. He has a complex course. He's an alcoholic, etc. encephalopathic, you know the deal. He is being tube fed, at goal, no issues. He has thrombocytopenia, they do a HIT panel which is positive. The MD stops heparin and starts argatroban but is suspicious as to whether this is really HIT and thinks its a false positive and sends blood for additional testing.
He is slowly progressing, up walking, etc. On day 10 in the hospital he has an acute event. Abdominal distinction, vomits, intubated, etc. he has an ischemic bowel, they do an ex lap and try to salvage. The bowel is necrotic and he dies a day later after family decides to stop pressures. Cause of death is ischemic bowel. In the d/c summery the MD states that the ischemic bowel may have been caused by the HIT but that he is unable to determine this conclusively. He also states that the second panel for HIT was negative. He also attributes the shock as being due to hypothermia, dehydration and possible "urosepsis".
The origional draft coding had the ischemic bowel as the Pdx. My feedback was that I didn't think it s POA and therefore could not be Pdx. She said that the presenting symptoms were indicative of ischemic bowel. I said the typical symptoms of ischemic bowel are abd distention, vomiting, diarrhea, and then increased WBC, shock, ect. I see no indication that it was POA. I have gone round and round with her but she is adamant that this is correct.
Am I missing something here? Clinically, do you see how someone could have an ischemic bowel for 10 days with normal bowel sounds, a soft abdomen and tube feeds at goal? I seriously baffled and second guessing myself.
And from a coding standpoint, would any of you be comfortable linking his presenting symptoms with an ischemic bowel. She asked her "friend" to look at it and her friend who has been a coder for 25 years) said she is right. I'm confused....
And then from a professional standpoint, what would you do? Our coding manager is out of town this week but I called her last night. She wants me to talk to the Dr and have him sign a POA query (likely stating no, in my opinion). This ocder has made is very clear she is annoyed at me getting invoved and said she doesn't see the point an any further discussion. I feel like I am further degrading our working relationship by taking this futher. At the same time, I am responsible for the accuracy of the death charts and i dont feel right about just letting this go.
I'd appreciate any insight.
Thanks!
Katy
Comments
Tracy M Peyton RN, CCDS
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406
Tracey Carey RN
Clinical Documentation Specialist
686-7421
Charlene
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley
Pull from record clinical indicators on presntation:
10 days with normal bowel sounds, a soft abdomen and tube feeds at goal.
Bowel sounds on admit and shortly after quote documentation
WBC on admit and shortly after quote lab values
Any CT abdomen that might have been done on admit
Shock/hyptension/hypothermia
Side note, any indicators of sepsis on admit?
Dorie
IF THE PHYSICAN DOES CLARIFY "POA" THEN THE CODER CAN STILL FEEL LIKE SHE WAS RIGHT AND IT IS CLEAR FOR YOUR AUDITORS AS WELL!
Juli Bovard RN CDS
Rapid City Regional Hospital
Rapid City, SD 57703
jbovard@regionalhealth.com
PS: I agree with you, sounds like it was not POA from your notes!
Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
not (from either my perspective as a coder or as a CDI reviewer) code
the Ischemic bowel as either POA or the principle diagnosis.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
Thanks for your help!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Office: 928.214.3864
Cell: 928.814.9404
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
srcole@phn-waco.org
Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
Good job! Unfortunately, I think we ALL get the "are you crazy" looks from the doctor. I don't think that the providers know that we know the answer before we ask, we just need clarity!
Don't you just love your job!
Juli Bovard RN CDS
Rapid City Regional Hospital
Rapid City South Dakota 57701
jbovard@regionalhealth.com
Paul Evans, RHIA, CCS, CCS-P, CCDS
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
I told the MD that I thought the D/C summery was clear, but I still needed to clarify for coding.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Office: 928.214.3864
Cell: 928.814.9404
Ugh....
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Office: 928.214.3864
Cell: 928.814.9404
CDI is a team program therefore it is imperative that both CDS and Coders have an understanding of each others role for this program to work.
Good luck!
Tracey Carey RN
Clinical Documentation Specialist
686-7421
Good Luck,
Mark
Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital
Information Technology
5255 Loughboro Rd NW
Washington DC, 20016-2695
W: 202.660.6782
F: 202.537.4477
http://www.sibley.org
So sorry you are having to work in that environment!
Jamie Dugan RN
CDI Specialist
904-202-4345
Baptist Health System Jacksonville, Florida
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Office: 928.214.3864
Cell: 928.814.9404