Better Diagnoses and DRGs for "Syncope and Collapse"

mdomineseymdominesey
edited May 2016 in CDI Talk Archive
In writing a plan on how to help with sign and symptom DRGs as well as other nonspecific DRGs, I have indentified MS-DRG 312 - Syncope and Collapse - to be a DRG that begs for a better principal diagnosis than Ortostatic hypotension, Iatrogenic Hyoptension and Syncope.

Any suggestions? I am thinking Dehydration is often the cause of Syncope, as is delirium. Some other common causes are Arrhythmia, CHF, Valvular Stenosis, and Neurologic diseases such as Parkinson's.

What do you folks suggest? Any particular query language to use to try and get "Syncope" clarified?

Thanks so much,

Mark



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

Comments

  • Unknown
    edited May 2016
    What about arrhythmias or anemia?


    Charlene Thiry RN, BSN, CPC, CCDS
    Clinical Documentation Specialist
    Quality Resources
    Menorah Medical Center
  • angelisa.romanelloangelisa.romanello
    edited May 2016
    Mark,
    Another possible diagnosis might be TIA or CVA.

    When I need further clarification I usually write: Based on the clinical indicators provided below, can you further clarify the etiology of the syncope.....then I list several items such as possible low hemoglobin, arrhythmias, dehydration, medications or neurological event.

    Lisa Romanello, RN,BSN,FNS,CCDS
    CDI Specialist
    CJW Medical Center
    Chippenham Campus
    804-228-6527
  • paxnerospaxneros
    edited May 2016
    Our query offers the following choices:

    Cardiac arrthymia
    Dehydration
    Anemia/Av Block
    Hypoglycemia
    Structural/Valvular Heart Disease
    Cerebrovascular Occlusion (Partial or Complete)
    Seizure Disorder
    Autonomic Neuropathy
    Vaso-vagel/Vaso-depressor
    N/A
    Other
    Unable to Determine
    None of the above
  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    What about carotid dz (DRG 67/68)? subsequent episode of care for a recent AMI (< 8 weeks) that is likely related to newly developed / developing conditions like cardiomyopathy or arythmias (314/315)? diabetes (hyper/hypoglyemia, DKA, and the associated dehydration)? autonomic neuropathy in DM causing orthostatic hypotension? carotid sinus syncope?

    Had to step away to discuss CDI with students in their last year of RHIT program....hopefully still something of use above.

    Don
  • robert.hodges2robert.hodges2
    edited May 2016
    I just query for the underlying cause or suspected cause.

    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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