"Covering For"

don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
edited May 2016 in CDI Talk Archive
Searched through coding clinic, etc. and can't find a firm reference.

When it is consistently documented "pneumonia, HCAP, covering for gram negative bacteria" -- but not "gram negative pneumonia" -- we still need to clarify with the physician for the gram negative pneumonia, correct?
Arrgh....we've had this conversation so many times that I can't remember what the expectation is & my partner (the coding manager) is gone for the day.

Don

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I feel the same about "empirically". "As in treating empirically for aspiration pna".

    I'm hoping for answers!

    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


  • sharon.colesharon.cole
    edited May 2016
    Had this same problem yesterday:

    This is the statement from the H&P and all progress notes:
    "HCAP, will cover for MRSA and double cover for pseudomonas with Vanc, Cipro, and Cefepime." It also mentions the previous hosp stay a month ago and that the patient has been in a nursing facility since that time.

    Coder said needed to be queried.
    Here's my query:
    "Please document the suspected etiology of patient's pneumonia. HCAP codes to and is reported as Pneumonia NOS unless a known or suspected organism is stated as the likely or suspected cause. "Covering for..." cannot be interpreted to mean this is what you suspect. "


  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    "Covering" is not a strong enough statement or documentation for coding of "Cause & Effect", or 'possible Cause & Effect", in my opinion. Staff will 'cover' for gram negative and gram positive pneumonia concomitantly and I would be reticent to code anything more than 486, Pneumonia, unspecified in such a situation.

    This would be a great question for the next quarterly ACDIS Conference Call.



    Paul Evans, RHIA, CCS, CCS-P, CCDS
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    Yes, query required.

    Paul Evans, RHIA, CCS, CCS-P, CCDS
  • ddouthitddouthit
    edited May 2016
    Yes, query necessary.

    Dorie Douthit, RHIT,CCS
  • vdavis2vdavis2
    edited May 2016
    See Coding says query! Love you, Dorie... this is why we all bounce stuff off of each other...I could defend that one clinically, so maybe a compromise!!! How about instead of querying... Let's go do some education with the DOC! When the doc gets it, hand the note back to him/her so they can review their own documentation... :)

    Vicki S. Davis, RN CDS
    Clinical Documentation Improvement Manager
    Health Information Management Department
    Alamance Regional Medical Center
    Office (336) 586-3765
    Ascom Mobile (336) 586-4191
    Fax (336) 538-7428
    vdavis2@armc.com

    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    Thanks to everyone for their input.

    Sigh...another post-discharge query.

    Don
  • afloydafloyd
    I know this post is really old, but we sent this question to Coding Clinic (it took almost 6 months to get an answer) and were told the same......query for clarification for either term of "covering for" or "empirically treating".

    April Floyd, RN, CCDS
    afloyd@andersonregional.org
Sign In or Register to comment.