expired pt. review

kshumpertkshumpert
in CDI Talk Archive
Has anyone had trouble bring the SOI up to a 4 DRG 215? When I use the Advanced analyzer, I get: No additional diagnosis or procedure codes suggested for this patient. THis of course is extremely helpful when I have used every MCC I could find:)

Comments

  • Unknown
    edited May 2016
    What was the cause of death?


    Tracey Carey RN
    Clinical Documentation Specialist
    686-7421

  • kshumpertkshumpert
    edited May 2016
    The patient had an MI, went for a CABG, went into cardiogenic shock, acute on chronic systolic CHF, went to CV Lab had an Impella placed, intubated- acute respiratory failure, shock liver, acute renal failure, metabolic acidosis, PEA

    Thanks,
    Kathy
    Kathy Shumpert, RN, CCDS

    Clinical Documentation Improvement Specialist
    Howard Regional Health System
    Office 765-864-8754
    Cell phone 765-432-3961
    Fax 765-453-8447

    When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela

  • Unknown
    edited May 2016
    Can you get look at the renal lab. Can you query the type of Acute Renal Failure IE ATN. That may help the SOI/ROM

    Tracey Carey RN
    Clinical Documentation Specialist
    686-7421


  • kshumpertkshumpert
    edited May 2016
    I tried ATN and it didn't make any difference in the SOI in comparison to ARF. Additionally, ATN and ARF, unspecified both have a SOI/ROM of 4/4. Thanks for the input though. I appreciate the help. These are the frustrating cases. I did a documentation review with this CV surgeon about a year and a half ago and pulled his expired patient data in. Ever since then he has been completely engaged and I can run right over to his office and get a query answered on an expired patient within minutes. It is so nice because those are high $$ charts that we don't like to keep hanging.

    Thanks,
    Kathy
    Kathy Shumpert, RN, CCDS

    Clinical Documentation Improvement Specialist
    Howard Regional Health System
    Office 765-864-8754
    Cell phone 765-432-3961
    Fax 765-453-8447

    When something can be read without effort, great effort has gone into its writing.  ~Enrique Jardiel Poncela



  • Unknown
    edited May 2016
    Unfortunately there are some reviews that you can't make a difference on. But this case has certainly brought interest.
    Thank you for sharing.

    Tracey Carey RN
    Clinical Documentation Specialist
    686-7421


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