PDX

dvitalone1dvitalone1
in CDI Talk Archive
What do you think PDx should be:
Direct admit 1 day prior to surgery of AAA repair.
Per H&P: "The patient is admitted to the hospital a day early for renal protection with a bicarbonate drip and Mucomyst."

Thanks for our input!

Comments

  • robert.hodges2robert.hodges2
    edited May 2016
    A query as to why the patient is receiving treatment without a diagnosis?

    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
     
    "We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley

  • angelamckee@uh.organgelamckee@uh.org
    edited May 2016
    The principal reason for the admission was the AAA surgery. The patient was admitted to the hospital a day earlyfor renal protection with a bicarb drip and mucomyst in preparation for the surgery. Since the reason for admission was for AAA surgery, AAA should be the principal dx. 
    Thank you,

    Angie McKee, RHIT, CCDS, CCS, CCS-P
    AHIMA Approved ICD 10 Trainer
    Clinical Documentation Specialist
    Performance Improvement
    University Health Care System
    Augusta, Ga.  30901
    706-774-7836  

  • robert.hodges2robert.hodges2
    edited May 2016
    I agree with a caveat. Is it standard that all patients be admitted a
    day early for renal protection, or does this patient have an underlying
    condition, such as chronic kidney disease, which requires the additional
    treatment prior to the surgery? If the patient has an underlying
    condition necessitating early admission, that should be captured.



    Robert



    VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence
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    "The difference between the right word and the almost right word is the
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    Clemens



  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    My understanding is that the AAA would be primary but if the early admission is not standard, we need a corresponding dx (CKD?).

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

  • paxnerospaxneros
    edited May 2016

    The AAA would be PDx. You would need a reason for medical necessity for the
    Renal Condition which prompted the day early admission. If one is not
    documented query for the condition.

    NBrunson, RHIA,CDIP, CCDS

  • vdavis2vdavis2
    edited May 2016
    Agree! The admit was occasioned by the AAA for Pdx....and I would capture the renal disease... That was a good case... going to share with our new CDS!

    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

  • mstanleymstanley
    Good Morning! When a patient is admitted with a symptom diagnosis such as syncope, hypoxia, or altered mental status, do you give the docs a couple of days to do the workup then query for definite diagnosis for the PDX? I find myself wanting to query right away for the "known or suspected cause of the symptom (______) which occasioned the admission." I feel that even at admission they should document some real diagnosis even if it is only suspected. Am I being unreasonable?
  • mdomineseymdominesey
    edited May 2016
    I usually give 24 hours from admission then I query for a suspected or possible diagnosis for the symptom.

    MND



    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
    Clinical Documentation Excellence
    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
    mdominesey@sibley.org

    http://www.sibley.org


  • elizabeth.hyndelizabeth.hynd
    edited May 2016
    I give them time for the work up. Often a Neurology consult and CT/MRI will shed light on the subject. I don't like to frustrate them before they've had time to figure it out. Occasionally they will talk about the symptom when there is a diagnosis blaring at them and them I query.

    Elizabeth Hynd RN, BSN, CPUR
    Clinical Documentation Specialist
    863-687-1100 ext. 7313

  • sharon.colesharon.cole
    edited May 2016
    If there is a workup in progress, I give them time to complete the workup.
    Sharon Cole, RN, CCDS
    Providence Health Center
    Case Management Dept
    254.751.4256
    srcole@phn-waco.org

  • vdavis2vdavis2
    edited May 2016
    I give them time to work up the condition... but I do prefer a list of differential diagnoses as a guide. I also find that list helpful when writing appeals for medical necessity cases. A differential list helps justify the need for admit by providing documentation of possible concerns and the "worst case scenario". You have to be proactive though on the cases that are likely to discharge quickly, so I would approach the physician sooner than later on those cases.

    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


  • robert.hodges2robert.hodges2
    edited May 2016
    I give them a day for work up. My queries ask what they suspect, are ruling out, or are treating as the cause of the symptoms. I may get "unknown" but at least I get them thinking. And if they are treating something, why not take credit for it since resources are being used. Of course, if it already says "unknown" I don't query until all labs or tests are back. But if they are treating something with IV medications or antibiotics, then it's fair game to query. Probably a good example of this is someone telling me (and I can't remember where or who) that when a patient is on antibiotics for pneumonia and the provider can't say what type of pneumonia they are treating, they tell the provider to stop the antibiotics. It does make a point.

    I keep reminding my providers that their medical judgment is critical and to put down "possible", "likely", or "probable" are all very legitimate descriptions of what they are treating and if they get something more definitive later, then they can document that at that time.

    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
     
    “Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge

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