coding question
I need some professional coding advice:
Pt admitted for lower GI bleed, hematuria - had a colonoscopy 3 weeks ago.
Coder's final:
PDx 455.8 unspecified hemorrhoids with complication
998.11 hemorrhage complicating a procedure. as a CC
My question is 998.11 is written in present tense and there was no procedure this admission to complicate.
My question to the coder: "If it is ok to refer to the previous procedure, can you use the hemorrhoids as the cause of the rectal bleeding with a cc as the cause of the rectal bleeding?"
Her answer: "complications have no time limit placed on them and can be present from procedures done previous to this adm"
I can't move beyond 'double dipping' in my mind and wonder what the RAC would think about this or is this ok by coding rules??
Thanks, I look forward to your thoughts,
Linnea Thennes, RN, BS, CCDS
Clinical Documentation Specialist
Clinical Resource Management
Northwest Community Hospital
847.618-3089
lthennes@nch.org
Pt admitted for lower GI bleed, hematuria - had a colonoscopy 3 weeks ago.
Coder's final:
PDx 455.8 unspecified hemorrhoids with complication
998.11 hemorrhage complicating a procedure. as a CC
My question is 998.11 is written in present tense and there was no procedure this admission to complicate.
My question to the coder: "If it is ok to refer to the previous procedure, can you use the hemorrhoids as the cause of the rectal bleeding with a cc as the cause of the rectal bleeding?"
Her answer: "complications have no time limit placed on them and can be present from procedures done previous to this adm"
I can't move beyond 'double dipping' in my mind and wonder what the RAC would think about this or is this ok by coding rules??
Thanks, I look forward to your thoughts,
Linnea Thennes, RN, BS, CCDS
Clinical Documentation Specialist
Clinical Resource Management
Northwest Community Hospital
847.618-3089
lthennes@nch.org
Comments
Pt presents with gi bleed... egd showed bleeding esophageal varices and hospitalist documented the same. But patient has known hx of etoh cirrhosis, portal htn, hepatitis c, alcoholism.
The ? is raised do I need to query for the link of esophageal varices 2nd to alcoholic cirrhosis? Or is it linked by the following coding notation where it says to code first underlying dz...
456.2 Esophageal varices in diseases classified elsewhere
code first underlying: Code first underlying disease, as: :: :: cirrhosis of liver (571.0-571.9) :: :: portal hypertension (572.3)
However; if I do that and pt has both portal htn and etoh cirrhosis can i pick either as my pdx? If i group it as a MS-DRG 572.3 is higher than 571.2. If I group to APR-DRG 571.2 is better than 572.3
Thanks for any advice you can give me/us. We are just unsure if we should be querying for the link of varices 2nd to cirrhosis/portal htn or if it is already linked and then if it is linked do we query for the more specific etiology of the esophageal varices being the portal htn vs the cirrhosis.
Hope this makes sense.
Angela Susott, CCS, CCDS, CPC