Myocardial Rule out
Good morning!
Currently we are having an issue with Chest Pain/Myocardial issues related to RULED OUT ect. We have been running into issues where our physicians, CNP's and PA's will document MI/STEMI/NSTEMI the ENTIRE way through the chart and then on the DC summary NOT say any of those diagnosis' AND not say RULED out either....the coders-coding from the entire chart will code the MI and there are a few fallouts related to the pt not truly having and MI.
Our AMI co-coordinator would like a query made up for MI ruled out ect. I see the one on the ACDIS website, but does anyone else have one that may be a bit less cluttered or friendly? We have been through the "education" with the docs on how and why the coders would code an MI and explained they cannot make the judgment that the pt DID NOT have one "after study" based on indicators, tests ect, but the docs would like to see query made so that a request can be made if the coders have any questions.... (currently our CDS only review Medicare-and we don't even get to see all those) ....ANYWAY...help of any kind would be appreciated.
Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
719-4390 (work)
786-2677 (cell)
"No Limit to Better......"
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
Currently we are having an issue with Chest Pain/Myocardial issues related to RULED OUT ect. We have been running into issues where our physicians, CNP's and PA's will document MI/STEMI/NSTEMI the ENTIRE way through the chart and then on the DC summary NOT say any of those diagnosis' AND not say RULED out either....the coders-coding from the entire chart will code the MI and there are a few fallouts related to the pt not truly having and MI.
Our AMI co-coordinator would like a query made up for MI ruled out ect. I see the one on the ACDIS website, but does anyone else have one that may be a bit less cluttered or friendly? We have been through the "education" with the docs on how and why the coders would code an MI and explained they cannot make the judgment that the pt DID NOT have one "after study" based on indicators, tests ect, but the docs would like to see query made so that a request can be made if the coders have any questions.... (currently our CDS only review Medicare-and we don't even get to see all those) ....ANYWAY...help of any kind would be appreciated.
Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
719-4390 (work)
786-2677 (cell)
"No Limit to Better......"
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
Comments
s an informational sheet we use to educate the MI, Core Measure team, CDI=
team and Coders .
The other is the actual query we use - these may not exactly fit your needs=
, but could be modified.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
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
[cid:image002.gif@01CDA6E6.275E1AE0]
http://www.sibley.org
asset to us for sure....
Jamie Dugan RN
Clinical Documentation Improvement Specialist
Baptist Health System
office:904-202-4345
cellular: 904-237-7253
Business Email-jamie.dugan@bmcjax.com
cdis.icd10@bmcjax.com