coding question

arobinso

Everyone,

Our ED coder (facility side) has been asking this question to lots of different sources and is not getting very good response. If anyone out there has input please let us know.

Question: Pt comes in ED with Kidney stone, IV fluids and IV pain meds are administered. The patient then goes to the OR for ESWL, and is kept in OBV status for 23 hours....where they also receive IV fluids and pain meds. As a coder would you code these fluids and pain meds(in ED and floor) and add modifier 59? This unbundles the visit,when you use encoder..... but what is correct???

Thanks Mandi

Mandi Robinson, RN, BS
Clinical Documentation Specialist
Trover Health System
270-326-4982
arobinso@trover.org
"Excellent Care, Every Time"


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robert.hodges2

I don't know about the coding, but I don't think that the patient should be in an observation status post procedure. If anything they should be in an extended recovery status. I'd run this issue past your UR department.

Sorry, my case manager background saw this one.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

arobinso

This was example, just trying to figure out if using the 59 in this case is appropriate, since if you leave it bundled you lose several hundred dollars at times. However, we want to code correctly, not just for reimbursement.

jolene.file

NormaB

The first question that pops into mind is where did the 900 code come from? Was this admission for rectal bleeding due to the previous colonoscopy? Did they cauterize or ligate polyps or hemorrrhoids on the previous admisson? In other words, is this the first admission since the colonoscopy?

If this rectal bleed is still due to the colonoscopy procedure the coder is correct about the length of time.

NormaB

I agree - iif the attending agrees with the GI doc re: the source of bleed, I belive the 900 should be listed first. Perhaps it was not clarified between the two docs?

CDI Talk wrote:

>Thanks Jolene - the attending said bleeding from hemorrhoids, the GI doc said hemorrhoids, cannot r/o possible bleeding from procedure. I am still stuck on PDx rectal bleeding from hemorrhoids with rectal bleeding from procedure as the cc - which sounds like you agree with my logic?

Unknown

My gut instinct is for the 998.11 to be coded first also, especially since doctor said he cannot rule out bleeding from procedure.

jolene.file

According to Coding Guidelines, Section II :Selection of Principal Dx- G) Complication of surgery and other medical care:
When the admit is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis.

Unknown

Before you would code this as a complication wouldn't you need to know that it was indeed due to the colonoscopy the patient has a few weeks before?




Malinda

fishdl@shands.ufl.edu

I would also question why the patient is still bleeding. Was the bowel perforated during the procedure? If so, wouldn't it be coded to 998.2?
Thanks.
Donna

Unknown

He said, "cannot rule out" which means to me the same as possible. I remember a coding guideline stating that if two or more possible's are given then you would code the condition first (bleeding) and the two possible's as secondary. This is definitely a tricky one. So maybe even GI bleed as primary, then the hemorrhoids and 998.11???

robert.hodges2

I am thinking this link cannot be presumed. If I recall correctly there are only a couple of things where a link can be presumed by coders and that isn't one of them. I asked my coder here and she said she would not be able to presume that link.

Robert

Robert S. Hodges, BSN, MSN, RN
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
 

pcavaness

What was the focus of care given to the patient?

Pamela J Cavaness, RHIT,CPC,CPC-H
HIM Director
Moore County Hospital District (MCHD)
224 E 2nd
Dumas, TX 79029
Phone 806-934-7805
Fax 806-935-3152
pcavaness@mchd.net

sharon.cole

Where was the thrust of treatment? Which dx better met IP criteria for medical necessity?

Sharon Cole, RN, CCDS
CDI Specialist
Case Management Dept
Providence Health Center
254.751.4256

Unknown

Follow the continuing drama of pneumonia vs dehydration…


Here is the first paragraph of the H&P: “Pt is a 76y/o female who presented to the ER brought by a friend d/t fatigue, dehydration, nausea, vomiting, cough and ill feeling. Pt states that she started taking the Levaquin that was prescribed as an outpt and she noticed she became nauseous. Pt states she was not drinking fluids very much. Pt states she was not eating well for several days and after she started taking the antibiotics, she felt nauseous, vomited. Denies diarrhea but felt ill and unable to drink fluid. Her friend saw she was ill and brought her to the ER. Assessment: pneumonia, dehydration. Plan: Continue IV fluids, Zofran if needed. Continue Zithromax.

Beginning of the discharge summary: “The patient is a 7u6y/o female who presented to the emergency room due to pneumonia, fatigue, dehydration and feeling ill. The pt was admitted and started on IV fluids as well as Zofran. The pt was also started on antibiotics, Zithromax and ceftriaxone and was given nebulizer treatments. The pt improved over her hospitalization…”

Linnea

robert.hodges2

All I can think of is the guidance on primary diagnosis which is the “condition after study that was determined to be the cause of the admission.” Even though it wasn’t documented in the H&P, it does sound like the pneumonia was present on admission and the dehydration was due to the treatment for the pneumonia. Just my two cents.



Robert



Robert S. Hodges, BSN, MSN, RN, CCDS

ssalinas

Could the patient's pneumonia have been treated with oral antibiotics as an OP had she not been dehydrated?

It could be argued the comparison given earlier re dehydration and ARF or dehydration and AGE are not quite valid here since there is a direct relation between those diagnoses. The pneumonia and dehydration, in this case, do not have that relationship. Consequently, there is a good argument for dehydration especially if the pneumonia could have been treated with oral antibiotics as originally planned had it not been for the dehydration that developed necessitating IV hydration.

Just my penny's worth....

Sharon

wfreeman

I will be out of the office on Friday, March 25, 2011. If you need
immediate assistance please contact the Case Management Department at
636-933-1226. Otherwise, I will return on Monday, March 28, 2011.

Thank you,
Bill Freeman, RN, BSN
Director of CDI
Jefferson Regional Medical Center
636-933-5324

robert.hodges2

Question one is what is the source of the sepsis you are treating? As I recall per coding guidelines for sepsis the source goes first then the sepsis.

Second, is if your providers have documented the acute kidney injury due to the sepsis, you now have severe sepsis.

You need to have codes for all three to take credit for severe sepsis.

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
 
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arsusott@msn.com

Thanks Robert,

The source of the sepsis is the pna. Treated for 2 days at another facility and then transferred to our facility for the acute renal failure. My question is does the transferring facility report sepsis as the pdx and we report the acute renal failure as pdx. Or can we still claim the sepsis is pdx since the acute renal failure was a "symptom" of the sepsis with organ dysfunction?

Thanks

dong.li

I think sepsis will be the pdx since it presented at admission as well. It does not matters that if the sepsis was due to pna.

thanks

evanspx@sutterhealth.org

Yes - the symptom code should not be reported (at all) as the etiology is documented - only the etiology is reported per Official Guidelines.

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