CVA residuals

Unknown
in CDI Talk Archive
We seem to be having a lot of CVA's this week where the patients are now unresponsive or minimally responsive to painful stimuli. The physicians are not really documenting any corresponding dx to represent these mental changes. One of the patients is on the vent for airway protection. What would be appropriate dx's that I could list in my query to them to describe the unresponsiveness of the patient? Is there anything to capture the vent need? Is acute respiratory failure appropriate in cases of airway protection?

Thank you for your ideas.

Lisa, RN
CDIS

Comments

  • wfreemanwfreeman
    Are you looking for an MCC or principle diagnosis? What about coma?
    Without seeing the chart, I am not sure, but it is worth checking into...
    780.01. We ask the CVA being primary and coma as secondary.

    Bill Freeman, RN, BSN
    Supervisor of CDMP
  • dbutlerdbutler
    edited May 2016
    We've had the conversation with our coding staff.....when pretty clear intubation is for airway protection, would NOT be appropriate to seek acute respiratory failure. Of course, look very closely to check that there was not respiratory failure presenting along with the CVA.

    As far as the unresponsiveness, agree that coma would be a good option.

    Don


  • dallend@einstein.edudallend@einstein.edu
    edited May 2016

    RE: vented for airway protection - if we have patients that are vented for airway protection we query for with one of the choices being dependent on mechanical vent. The code is V 46.11. Our physicians seem to be very comfortable documenting this since they state that the patient is not in respiratory failure. Some of our docs do document VDRF also.
    As far as the changes in mental status - I would just list them and ask for a diagnosis unless you have a chance to speak with them in person. Are there changes in the CT or MRI to explain this change. Are there other changes that could account for this? I find these things are best handled one to one if you have the chance.


  • robert.hodges2robert.hodges2
    edited May 2016
    Call me simple, but without a primary diagnosis and only symptoms being documented I query to ask what the underlying causes of the symptoms are. That way it’s not leading. I’d also ask them if they are not sure to document what they suspect or are ruling out.



    Robert



    Robert S. Hodges, BSN, MSN, RN

    Clinical Documentation Improvement Specialist

    Aleda E. Lutz VAMC

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  • lspryszaklspryszak
    Agree that acute respiratory failure would be inappropriate. Also, remember that vented patients are often kept sedated to prevent agitation and potential traumatic extubation - a probable cause of unresponsiveness.

    I would carefully analyze the extent of the CVA, look for cerebral edema, swelling of the brain, etcetera, as these are often not documented. These could be a contributing factor to decreased responsiveness. I review the CT scan for evidence of midline shift, extent of the stroke (if ischemic vs. hemorrhagic) because a bleed will be space-occupying, which can lead to cerebral edema or swelling of the brain, both MCC conditions.

    Encephalopathy due to either the stroke and/or medications may be a viable option, after discussion with the intensivist or neurologist.

    Some others which may be appropriate at some point, given the ICU setting: acute delirium (293.0), critical care myopathy (359.81), post-traumatic psychosis (293.9.
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