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
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
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.
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
suspected infection. Clinically, the Systemic Inflammatory Response
Syndrome (SIRS) is the occurrence of at least two of the following
criteria: fever >38.0
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
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.
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
Debra Stewart RN, BSN
Clinical Documentation Specialist
Sentara/Halifax Regional Hospital
South boston, va. 24592
(434)-517-3317 Work
(434)-222-9884 Cell
Debra Stewart RN, BSN
Clinical Documentation Specialist
Sentara/Halifax Regional Hospital
South boston, va. 24592
(434)-517-3317 Work
(434)-222-9884 Cell
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
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