Traumatic SDH/SAH
When a patient has a traumatic brain injury is Brain compression inherent in that code?
I know that at one time it was a component so no need to Q for it, but I thought that rule changed and now the Query is viable for compression from intracranial bleeds/swelling due to injury. Am I dreaming? Or can any of you master coders clarify this for me with a correct reference?
Thank you!!
Jane Hoyt, BSN, RN, CCDS
Manager, Clinical Documentation Integrity
Health Information Management
PAV A, 5th Floor, #505
Mail Code 1801
Denver Health and Hospital Authority
303.602.3830
Jane.hoyt@dhha.org
Think with Ink☺
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, September 11, 2012 1:56 PM
To: Hoyt, Jane RN
Subject: RE: [cdi_talk] Provider Responses
We recently had this conversation. I addressed it with leadership because although I want to make our program "look good", I don’t think it's accurate to mark it as answered. Additionally, it warps the data so we are less able to determine which providers are answering and which aren’t.
However, leadership disagreed and just wants it marked as answered if the necessary data ends up in the record. Whether it's as a response to our direct query or not and regardless of who actually answers it. So, that’s what I'm doing.
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
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, September 11, 2012 3:06 PM
To: Kathryn Good
Subject: [cdi_talk] Provider Responses
If you write a query to a provider and an alternate provider later documents what you were looking for (without seeing the query) do you: Give credit to the documenting provider? Give credit for your query?
We currently mark these as "agreed" by the documenting provider but I'm not sure if we can really take credit.
Thanks!
Megan Barton RN, BSN
Manager CDI - Mercy East St. Louis
314-251-6192
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Copyright 2012
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Copyright 2012
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I know that at one time it was a component so no need to Q for it, but I thought that rule changed and now the Query is viable for compression from intracranial bleeds/swelling due to injury. Am I dreaming? Or can any of you master coders clarify this for me with a correct reference?
Thank you!!
Jane Hoyt, BSN, RN, CCDS
Manager, Clinical Documentation Integrity
Health Information Management
PAV A, 5th Floor, #505
Mail Code 1801
Denver Health and Hospital Authority
303.602.3830
Jane.hoyt@dhha.org
Think with Ink☺
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, September 11, 2012 1:56 PM
To: Hoyt, Jane RN
Subject: RE: [cdi_talk] Provider Responses
We recently had this conversation. I addressed it with leadership because although I want to make our program "look good", I don’t think it's accurate to mark it as answered. Additionally, it warps the data so we are less able to determine which providers are answering and which aren’t.
However, leadership disagreed and just wants it marked as answered if the necessary data ends up in the record. Whether it's as a response to our direct query or not and regardless of who actually answers it. So, that’s what I'm doing.
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
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, September 11, 2012 3:06 PM
To: Kathryn Good
Subject: [cdi_talk] Provider Responses
If you write a query to a provider and an alternate provider later documents what you were looking for (without seeing the query) do you: Give credit to the documenting provider? Give credit for your query?
We currently mark these as "agreed" by the documenting provider but I'm not sure if we can really take credit.
Thanks!
Megan Barton RN, BSN
Manager CDI - Mercy East St. Louis
314-251-6192
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: kathryn.good@nahealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12649561.a6bbaf3538c19e934e5136fbd051a6b1@hcprotalk.com
---
Copyright 2012
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jane.hoyt@dhha.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-13436162.01a623fa4ab80795319c85daea0b6edb@hcprotalk.com
---
Copyright 2012
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
The Denver Health email system has made the following annotations
---------------------------------------------------------------------CONFIDENTIALITY NOTICE - This e-mail transmission, and any documents, files or previous e-mail messages attached to it may contain information that is confidential or legally privileged. If you are not the intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that you must not read this transmission and that any disclosure, copying, printing, distribution or use of any of the information contained in or attached to this transmission is STRICTLY PROHIBITED. If you have received this transmission in error, please immediately notify the sender by telephone or return e-mail and delete the original transmission and its attachments without reading or saving in any manner. Thank you.
Comments
Compression
with injury - see specific injury
arm NEC 354.9
artery 447.1
celiac, syndrome 447.4
brachial plexus 353.0
brain (stem) 348.4
due to
contusion, brain - see Contusion, brain
injury NEC - see also Hemorrhage, brain, traumatic,
laceration, brain - see Laceration, brain
However I have pasted the CC you are referring to below and it seems to indicate you can code it separately when documented. I think I would go with the code book though and not code it separately until there is clarification from CC. Brain edema can be coded separately.
Shift and mass effect and brain compression
Coding Clinic, Third Quarter 2011 Page: 11 Effective with discharges: September 23, 2011
Question:
The patient suffered an acute subdural hematoma with shift and mass effect. We have been instructed by a consultant that shift and mass effect are clinically synonymous with brain compression and should be coded as such. Would it be appropriate to assign code 348.4, Compression of brain, based on the provider’s documentation of "mass effect or midline shift"?
Answer:
The coder should not make the assumption that midline shift or mass effect is synonymous with brain compression. The coder should query the provider and if the provider clarifies and documents that the "mass effect" or "midline shift" is brain compression, the coder may then assign a code for the brain compression.
Sharon Salinas, CCS
Barlow Respiratory Hospital
213-250-4200 Extension 3336
I would be excited if the guidance had changed though so I will keep an eye on this thread….
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
Cindy