coding on death charts

annnd2009@gmail.comannnd2009@gmail.com
in CDI Talk Archive
I had a query outstanding for a confused patient post mi with stents/ptca pdx:MI--in ICU for AMS/Encephalopathy...

while waiting for response...pt coded and died. Prior to the query it did not have a MCC only a cc and soi/rom score of 2/2.

When I was looking for answer and saw that they died. I saw that they were placed on dobutamine, became apneic, bradycardia ...

So I additionally queried for shock and acute respiratory failure.

The doctor did say yes to the encephalopathy but no to the shock and respiratory failure. The cardiac arrest will not be an mcc on a patient NOT discharged alive.

I do not have much experience with this...any suggestions of better questions I should have asked or education I should work on? Or was I totally unreasonable with my questions?

Also though the cardiac arrest does not get MCC status--is it still coded? Does it still impact soi/rom?

Thank for any input!

Ann Donnelly
ann.donnelly@sclhs.net

Comments

  • Unknown
    edited May 2016
    In my limited experience I would say it should all be coded as it all did happen while the patient was alive. If it happened and was treated then it should be coded.

    Mary L. Snook RN-BC
    Clinical Documentation Specialist
    Medical Information Services
  • vdavis2vdavis2
    edited May 2016
    Cardiac arrest is Excluded for both SOI/ROM when the patient expires.

    I think I would query to see what condition was treated with the dobutamine, and ask the MD to document the underlying cause, if know for the patient's apnea and bradycardia.

    In regards to respiratory failure, ask the physician to provide the clinical significance (if any) for abnormal ABG results, abnormal vital signs, and/or the use of oxygen therapy treatments. Sometimes asking the question in those terms helps the physician to understand the "nuts and bolts" behind the query.

    If you are able to talk with the physician, I would approach this case from a Risk of Mortality perspective. We have been able to partner with our physicians through our mortality review process.

    If I can do anything to help on this case, let me know. :)

    Have a Happy Thanksgiving!-V


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