OB and Trauma
Up until this point, I have been under the impression that if a patient is pregnant and hospitalized for virtually any reason, the pregnancy will drive the DRG. The exception being cases where the pregnancy was truly irrelevant (for ex: traumatic fx requiring repair in the early first trimester). In these instances the MD needs to document that the pregnancy was incidental.
However, I recently read a post on the blog (I think?) that suggested that if the pregnancy was not the focus of care, that we should query the MD for this documentation (pregnancy as incidental), even if some care was directed at the pregnancy (monitoring, poss OB consult, Rx considerations, etc).
I have a current case where a women was in a serious MVC and is 6mo pregnant. Pt has multiple traumatic injuries including spinal fx, clavicle fx, rib fx, pneumo, etc and required spinal surgery. Baby appears fine.
Thoughts?
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
However, I recently read a post on the blog (I think?) that suggested that if the pregnancy was not the focus of care, that we should query the MD for this documentation (pregnancy as incidental), even if some care was directed at the pregnancy (monitoring, poss OB consult, Rx considerations, etc).
I have a current case where a women was in a serious MVC and is 6mo pregnant. Pt has multiple traumatic injuries including spinal fx, clavicle fx, rib fx, pneumo, etc and required spinal surgery. Baby appears fine.
Thoughts?
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
I read your post with great interest. We have struggled with this here at New Hanover, also as we also receive a large volume of traumas and high risk pregnancies. We had a consulting company here which gave us the following guidance;
"It is the provider's responsibility to state that the condition being treated is not affecting the pregnancy".
That being said, I think it would be challenging for any physician to state that the anesthesia, medications, treatments, etc.. would not affect the pregnancy, much less document it as such.
The pregnancy would always be a consideration when providing treatment in your described case and probably most cases requiring inpt admission.
We analyze each of these cases heavily before deciding to query for "pregnancy incidental to the encounter". The majority of the time we take it to the pregnancy DRG, even though their weights are very low. We think it is the right place to be.
Just my thoughts....hope this helps!
Thanks,
Linda
Linda Rhodes RN, BSN, CCDS
Manager Clinical Documentation Improvement
New Hanover Regional Medical Center
Wilmington, North Carolina
Office # 910-815-5544
Cell " 910-777-8344
e-mail : linda.rhodes@nhrmc.org
I believe your correct in pregnancy is going to drive your DRG. If a patient is pregnant unless physician specifically states pregnancy incidental to trauma your pregnancy would have to be your principal. In the instance of your current case, I imagine the pregnancy guided the treatment rendered, i.e. drugs given, anesthesia rendered, etc. therefore pregnancy would have to be your principal.
Even if the pregnancy is not the focus of treatment in trauma cases, I don't think the pregnancy is incidental.
There is a 9/24/13 CDI talk that also discusses this topic.
Dorie Douthit RHIT,CCS
AHIMA-Approved ICD-10-CM/PCS Trainer
ddouthit@stmarysathens.org
Clinical Documentation Specialist/HIM
St. Mary's Healthcare System
Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com
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Donna
Donna Fisher, CCS, CCDS
CDI Coordinator
UFHealth Shands Hospital
Ph: 352.265.0680 ext 48769
fishdl@shands.ufl.edu
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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