Organism? HELP!

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
I have a patient with LLE cellulitis/abcess that was debrided/excised.
Later, we have documentation that says:

continues to do well. Culture + group C strep. Abx changed to unasyn, cont clindamycin (antitoxin effect) x 3 days total. If clinical course continues to go well, may be able to transition to oral abx on discharge...although c her size and extent of infection, I wouldn't be opposed to IV abx course of 10 days or so. Suspect she'll need SNF anyway for wound vac (lives in remote area).
- leg per surgery - vac on currently
- chronic leg ulcer biopsied - negative for malignancy


Is this enough to tie it to the wound even though the wound is not really mentioned here?

Thanks!!

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

Comments

  • cmclose@saintfrancis.comcmclose@saintfrancis.com
    edited May 2016
    I would be interested in other's opinions of this as well. My understanding is the organism needs to be specifically linked to the condition to code it, ie "MRSA pneumonia"(DRG 179), as opposed to common documentation that I see such as "Pt with Pneumonia, pt tolerating IV Vanc. Afebrile. Sputum cx + for MRSA" (DRG 195).

    Claudine Hutchinson RN
    Clinical Documentation Improvement Specialist
    Children's Hospital at Saint Francis
    Email: chutchinson@saintfrancis.com

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Hmmm.... Now on that one, if the MD documented that the cx was positive for MRSA under the heading of PNA, I would assume that’s ok. Maybe I am wrong on that?
    I am perplexed on this one because this documentation is not under the heading of Wound/abscess or something similar. It is just a 'floating' narrative.
    My advice is "when in doubt, query", but I have a CDS who is stating that she feels it is unnecessary so I want to get other opinions on it.

    Thanks!

    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

  • cmclose@saintfrancis.comcmclose@saintfrancis.com
    edited May 2016
    Katy~ I have seen some coders will code it from a note of +sputum cx for MRSA in a pt with pneumonia (I tend to agree with this but since I am not a coder I usually query just to be on "safe side"), other coders will not unless it is specifically charted as "MRSA pneumonia" so I am interested on other's opinions too. Sometimes this can be a frustrating "game" to "play". :-)
    Claudine Hutchinson RN
    Clinical Documentation Improvement Specialist
    Children's Hospital at Saint Francis
    Email: chutchinson@saintfrancis.com


  • gail.eatongail.eaton
    edited May 2016
    Kathy-
    I would query for the anatomical site of the infection. In this day and age of documentation you can never be too specific. :)

    Gail Eaton RN PCCN CDS
    Clinical Documentation Specialist

    St Joesph Health
    2700 Dolbeer, Eureka, Ca, 95501
    Office: 707-445-8121 ext 7555
    Cell: 707-267-0279
  • jolene.filejolene.file
    edited May 2016
    Good Morning, Katy!

    I would not assume a linkage and would query. Check out C. Clinic, 3rd Qrtr. 2012,Associated conditions & documentation of a linkage. ANSWER: It is not required that two conditions be listed together in the health record. However, the provider needs to document the linkage, except for situations where the classification assumes an association (e.g. hypertension with chronic kidney involvement).

    Enjoy you Friday.

    Jolene File,RHIT,CCS,CPC-H,CCDS
    Documentation Improvement Specialist-Coder
    Hays Medical Center
    jolene.file@haysmed.com

    IMPORTANT: This communication contains information from Hays Medical Center which may be confidential and privileged. If it appears that the communication was addressed or sent to you in error, you may not use or copy this communication or any information contained therein, and you may not disclose this communication or the information contained therein to anyone else. In such circumstances, please notify me immediately by reply email or by telephone. Thank you.

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    It is hard to overstate that the physician documentation must be explicit - even when the clinical situation seems, very, very obvious. The MD MUST link the organism to the disease, IMO. Below are references from Coding Clinic. A facility is not allowed to code solely from any culture results.



    AHA Coding Clinic
  • cmclose@saintfrancis.comcmclose@saintfrancis.com
    edited May 2016
    Thanks Paul.

    Claudine Hutchinson RN
    Clinical Documentation Improvement Specialist
    Children's Hospital at Saint Francis
    Email: chutchinson@saintfrancis.com

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