post-op infection??
I am performing a retro internal audit and am confused about PDX/DRG assignment on this patient. This patient was transferred to our facility and had a 9 day LOS. Initially the documentation is very clear. He is s/p a lisfranc amputation and has peri-incisional necrosis. We have documentation of wound dehissence and tissue loss. We have cellulitis documented as a ‘spread of wound infection’. We have documentation of ‘post-operative wound infection growing serratia’. The patient ends up having a BKA. Then, on day 6 we have a new hospitalist come on service and he states /chronic leg ulcer with necrosis’. This documentation is carried though until discharge and into d/c summery.
No complication codes were applied on this record and the coder selected atherosclerosis with gangrene as the Pdx putting us in DRG 240. Is this correct?
I am going to include some specific documentation from the record:
• Status post left foot Lisfranc amputation 07/11/2013 with 2008 transmetatarsal amputation
• presenting with multiple areas of peri-incisional wound necrosis, H&P
• necrosis of his suture lines and near breakdown of the amputation and the patient was transferred to Flagstaff for a vascular workup of this left lower extremity regarding the breakdown of the wound. Consult 07/24
• Recent Left forefoot amputation that is associated with wound dehissence and impending tissue loss. 07/24 Consult
• transferred for evaluation of necrosis at the site of a recent Lisfranc amputation. Necrosis of Lisfranc amputation Surgical 07/25
• Wound necrosis: Patient with peripheral arterial disease as noted above compromising wound healing and appears to heavy wound infection with spreading cellulitis and likely osteomyelitis. Blood cultures are NGTD and patient continues on vancomycin and zosyn pending surgical control of infection. Operative risk is high given hx of cardiomyopathy, CAD, DM2 uncontrolled. Hospitalist 07/25
• Cellulitis: Likely spread of wound infection, treatment as above. hospitalist 07/25
• Wound necrosis: Patient with post operative wound infection growing serratia and some surrounding cellulitis. Ultimately patient had BKA.Given source of infection removed and blood cultures no growth, will stop antibiotics. 07/26 hospitalist
• Left leg chronic ulcer with necrosis: Status post left below knee amputation.07/29 NEW hospitalist. Same on 07/30
thanks for your help!
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
No complication codes were applied on this record and the coder selected atherosclerosis with gangrene as the Pdx putting us in DRG 240. Is this correct?
I am going to include some specific documentation from the record:
• Status post left foot Lisfranc amputation 07/11/2013 with 2008 transmetatarsal amputation
• presenting with multiple areas of peri-incisional wound necrosis, H&P
• necrosis of his suture lines and near breakdown of the amputation and the patient was transferred to Flagstaff for a vascular workup of this left lower extremity regarding the breakdown of the wound. Consult 07/24
• Recent Left forefoot amputation that is associated with wound dehissence and impending tissue loss. 07/24 Consult
• transferred for evaluation of necrosis at the site of a recent Lisfranc amputation. Necrosis of Lisfranc amputation Surgical 07/25
• Wound necrosis: Patient with peripheral arterial disease as noted above compromising wound healing and appears to heavy wound infection with spreading cellulitis and likely osteomyelitis. Blood cultures are NGTD and patient continues on vancomycin and zosyn pending surgical control of infection. Operative risk is high given hx of cardiomyopathy, CAD, DM2 uncontrolled. Hospitalist 07/25
• Cellulitis: Likely spread of wound infection, treatment as above. hospitalist 07/25
• Wound necrosis: Patient with post operative wound infection growing serratia and some surrounding cellulitis. Ultimately patient had BKA.Given source of infection removed and blood cultures no growth, will stop antibiotics. 07/26 hospitalist
• Left leg chronic ulcer with necrosis: Status post left below knee amputation.07/29 NEW hospitalist. Same on 07/30
thanks for your help!
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
Difficult record. If the pt. has a postop infection & postop wound dehiscense, in my opinion, the principal dx. would be the postop wound infect (998.59). However, if the DS documents the patient did not have postop infection and only the PAD with gangrene and ulcer, than the correct code would be 440.24 + 707.XX (ulcer code).
I think that a query should have been written asking about the postop infection if it was not on the discharge summary. I would have chosen the postop infection because it sounds like it was clearly documented within the record. Because the DS did not include it, it could be considered contradictive. The thrust of treatment was directed at the infection by the BKA performed.
Another thing to think about is the osteomyelitis. If the pt. has diabetes & osteomyelitis, I-9 assumes a relationship & the diabetes would be the principal dx.. Let's say the pt. did not have a postop infection & that the BKA revealed osteomyelitis, than I believe the diabetes code (250.XX) would be principal.
Hope that my opinion & thoughts are helpful. Good Luck!
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.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
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
I appreciate your feedback and thanks for the tip about the Osteo. He did not mention it in the op-note, but I am going to look a little more closely at the record to make sure it wasn't elsewhere in the record.
Happy Friday!
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
I can't take the time to adequately address this complicated issue, but it is very common. I can tell you I 'feel' that outside 3rd parties have become rather aggressive in the last few years, making some coders somewhat reticent to code major diagnoses that are not reliably stated throughout the chart.
For instance, 5 years ago I can tell you I would surely code Encephalopathy in a patient with a major neurological disorder if this was stated by a consulting neurologist and the condition AMS is listed by the Attending (Dissonance)? Now, with the new practice brief stating we have a duty to confirm, I may not code in this manner, but will issue a query.
Coders see this scenario repeated every day, and are held accountable, too. I have a RAC denying the coding of Encephalopathy documented by a neurologist, but called "AMS" in the summary by the Hospitalist and the RAC states the diagnosis issued by the specialist is 'not reliable'.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
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