Trauma/assault *warning: this may be upsetting*

I have a coder who has reached out for some help with a complex record. It is a patient who was found down, encephalopathic, naked, and hypothermic. This women is an alcoholic, likely homeless with minor injuries of various ages/stages of healing. Sexual/physical assault is suspected but there is no documentation of vaginal bleeding, vaginal or perineal injury, etc. All we have injury wise is chest contusions and minor scrapes, bruises and such.
In the d/c summery the MD states that the encephalopathy (which was the focus of care, she took a LONG time to clear and was admitted for 5 weeks) was due to infection. Patient was intubated and on the vent for a period of time and also required a G-tube for a period of time for dysphagia.
The coder is concerned because she says that according to the guidelines she must sequence the assault first. But we don't have any significant injuries to code as the Pdx. Currently, she is stuck with 924.8 (contusion of multiple sites) as the Pdx but this seems problematic.
I am wondering if anyone has any guidance on this. From my perspective it doesn’t seem like the assault was the reason for admission. She was admitted due to the encephalopathy which is not attributed to the assault. If this patient had not been hypothermic and encephalopathic, she would not have been admitted due to the assault. She would have been treated in the ED and discharged.

Thank you!

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

  • edited May 2016
    In my opinion, if the pt. was not treated for the minor injuries & not the reason for admit than it should not be the principal dx. Definition of principal dx. is condition after study to occasion admit to the hospital. With the encephalopathy due to infection, wondered if the pt. met clinical criteria for sepsis. I would research the I-9 Coding Guidelines, C. Clinic & Faye Brown to see if you could find something more to support your decision. 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.
  • Thanks Jolene!
    The patient may have been septic on admission. This is something I thought as well. We end up having aspiration pna as POA but 'SIRS' is not documented until several days into the stay. This was something I was considering querying for as well. She was very hypothermic on admission but had a WBC of 26!

    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
  • "Sepsis is a systemic inflammatory response to a confirmed or
    suspected infection. Clinically, the Systemic Inflammatory Response
    Syndrome (SIRS) is the occurrence of at least two of the following
    criteria: fever >38.0
  • Yup. Absolutely. The SIRS 2/2 infection will code to sepsis. This is currently POA(N) but it may really have been POA(Y). They initially are attributing the WBC's to a stress response but its nuclease because it took them a few days to really figure out what was going on with this patient.

    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
  • edited May 2016
    You are welcome,Katy. Another thought for your coder is to submit a question to AHA Coding Clinic relating to the case. C.Clinic advice is online and can be accessed 24/7 for FAQ's. The Website is: www.CodingClinicAdvisor.com.
    Hope that is helpful.

    Jolene File,RHIT,CCS,CPC-H,CCDS
    Documentation Improvement Specialist-Coder
    Hays Medical Center
    (785) 354-7120
    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.
  • 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
  • Oh yes see your comment now about sepsis, asp pna, would seem this should carry as PDX w/vent
    Debra Stewart RN, BSN
    Clinical Documentation Specialist
    Sentara/Halifax Regional Hospital
    South boston, va. 24592
    (434)-517-3317 Work
    (434)-222-9884 Cell
  • It seems to me that the Encephalopathy (treatment geared to that) would be your PDX, not assault.

    Debra Stewart RN, BSN
    Clinical Documentation Specialist
    Sentara/Halifax Regional Hospital
    South boston, va. 24592
    (434)-517-3317 Work
    (434)-222-9884 Cell
  • edited May 2016
    I agree as well... I don't think the assault occasioned the admit unless the doc's linked the enceph to a specific injury obtained during the assault, but that doesn't seem like the case from your notes. I would explore the Sepsis side... hard for me to believe she wasn't septic, but given her chronic alcoholism, it could take a while for her mental status to clear. I case managed a similar patient when I worked at another hospital. Guy was found almost naked, passed out in a van with his door open on a very cold night. He was brought in with hypothermia, ETOH abuse/intoxicated, enceph, asp. Pneumonia, ARF, and he had also suffered an NSTEMI. It took weeks for the patient's mental status to clear. This guy was so intoxicated that he tried to urinate out the driver's side door of his van. He passed out before he finished and closed the door.

    Good luck with this one Katy… I know you are thankful you were not the case manager for this patient!

    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
  • Thanks Vicki!

    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
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