query for complication

ddouthit

Suggestions for verbiage for complication of internal device query for below scenerio? Need to query for linkage.

Patient presented with Left arm swelling. Patient is ESRD with left subclavian venous dialysis catheter. Patient had an ultrasound, duplex done of the left arm which shows positive for acute deep venous thrombosis involving the left internal jugular, subclavian, and axillary veins.

Thanks,

Dorie Douthit RHIT,CCS

robert.hodges2

The only thing I can think of is to ask if they have a suspected cause or source of the DVT you describe. I'm attaching the VHA cause and effect query which may help some.

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

katysuegood@gmail.com

I too would ask for an underlying cause.

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

evanspx@sutterhealth.org

Can not attach the query form due to size restrictions - but I am replying with some suggested verbage-




Dear Physician/PA/NP: ____________________________________________________________________ or other responsible provider:
For accurate coding and severity-of-illness compilation, this query is directed to you. When responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.

Patient presented with Left arm swelling. Patient is ESRD with left subclavian venous dialysis catheter. Patient had an ultrasound, duplex done of the left arm which shows positive for acute deep venous thrombosis involving the left internal jugular, subclavian, and axillary veins

A cause-and-effect relationship between diagnoses may not be assumed and must be explicitly documented . Please document the cause-and-effect relationship, if any, between these conditions.






CDI Specialist/Coder: _________________________________ Date:_____________ Time: _______________



PHYSICIAN/PA/NP Response:

0 Clarification of findings: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

0 No Association 0 Cannot be determined


Paul Evans, RHIA, CCS, CCS-P, CCDS

Supervisor, Clinical Documentation Integrity, Quality Department California Pacific Medical Center