Pdx sequencing question
Hi! Working on a coding/CDI discrepancy over Pdx assignment. Any input would be appreciated. Pt with myelofibrosis and chronic anemia. She was initially admitted as an OBS and then became inpt secondary to neurological symptoms and a possible stroke. Acute stroke was ruled out; symptoms were thought to be an aggravation of a previous stroke secondary to the anemia. Pt received one unit of blood on day two of admission. Pt was advised that her anemia was secondary to progressing myelofibrosis would continue. The pt chose palliative care and was discharged home with hospice. Of note, she also had aspiration pneumonia POA that was treated with IV abx throughout the 6 stay. Thank you for your help with this complex case!
Jillian Lightfoot CDI RN
Marshall Medical Center
(530) 626-2770 Ext. 6203
jlightfoot@marshallmedical.org
Jillian Lightfoot CDI RN
Marshall Medical Center
(530) 626-2770 Ext. 6203
jlightfoot@marshallmedical.org
Comments
Anemia and ASP PNA both POA?
The etiology of the PNA r/t Neuro S/S???? if so, I would go with
PDX: ASP PNA
both treated. but what extended the LOS ?
Whenever pt is OBS to IP follow UHDDS rule "the condition established after careful study to be..."
Janet Schoen, RN, Clinical Documentation Specialist
Clinical Resource Management
JSchoen@CHS-MI.com
office phone 989-583-7192
Thanks for your reply. I was hoping to use the myelofibrosis as the Pdx. From a clinical view point the progression of the myelofibrosis was the cause of the anemia and was treated by the palliative care team, including physician consults, case management, family conference etc. Ultimately, the patient and family decided to go home with hospice because of the now terminal progression of the myelofibrosis. Our coding team feels that the anemia is the Pdx.
Of note, it's so hard to put an entire case into a short email, the aspiration pneumonia was possible and not included on the discharge summary. We're currently waiting for MD response to a post discharge query. If still a possible diagnosis, I will recommend the aspiration pneumonia as the Pdx.
Again, thanks for your input.
Jillian Lightfoot RN
Clinical Documentation Team
Marshall Medical Center
Placerville, CA 95667
(530) 626-2770 Ext. 6203
jlightfoot@marshallmedical.org
admission following medical observation is the condition occasioning to admission of
the patient to the hospital for care.
ICD-9-CM Official Guidelines for Coding and Reporting Effective October 1, 2011 Page
90 of 107
1. Admission Following Medical Observation
When a patient is admitted to an observation unit for a medical condition, which
either worsens or does not improve, and is subsequently admitted as an inpatient of
the same hospital for this same medical condition, the principal diagnosis would be
the medical condition which led to the hospital admission.
Thank you,
Angie McKee, RHIT, CCDS, CCS, CCS-P
AHIMA Approved ICD 10 Trainer
Clinical Documentation Specialist
Performance Improvement
University Hospital
1350 Walton Way,
Augusta, Ga 30901
· Anemia was the cause of the neurological symptoms which caused IP admission
· Regarding the myelofibrosis- I thought of it in the same way we would code anemia due to neoplasm as the principal diagnosis when admitted for treatment of the anemia
· Regarding aspiration pneumonia – was it present when she was admitted to OBS? If so, it seems it was not deemed a reason for IP admission (Perhaps it could have treated with po abx if the neurological issues did not arise?)
As someone else said it is difficult to analyze a case with limited information, but based on info provided I would use the anemia as the principal dx.
Sharon Salinas, CCS
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
ssalinas@barlow2000.org
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