post op complication

sindhusamsonsindhusamson
in CDI Talk Archive
I have a patient transferred from another hospital due to 3rd degree heart block during the hernia surgery and patient received a pacemaker from our hospital. What will be the principal diagnosis for this patient. cardiac complications (997.1) or conduction disorders(426). Please advise.

Comments

  • sbeattysbeatty
    edited May 2016
    Your statement says he was transferred due to 3rd degree heart block.
    The treatment of the heart block is the reason for the transfer to your
    facility, correct? I believe based on the info at hand that the heart
    block is your PDx. That is the condition that required IP admission to
    YOUR facility. Ultimately, it would depend on what is documented by your
    MDs in your MR. I defer to our coder colleagues.

    Sandy Beatty, RN, BSN, C-CDI
    Columbus Regional Hospital
    2400 E. 17th Str.
    Columbus, IN 47201
    (O) 812-376-5652 (M) 812-552-6997


    "Great leaders are almost always great simplifiers, who can cut through
    argument, debate, and doubt to offer a solution everybody can
    understand."

    General Colin Powell


  • jolene.filejolene.file
    When the documentation supports a complication, the Official Coding Guidelines should be followed.
  • davisd2davisd2
    I was wondering about an ileus today as well. Pt is Status post retroperitoneal resection of recurrent liposarcoma(14 days from another facility)
    Do I code that as a complication without further clarification or do I have to get the MD to link the ileus to the surgery as a complication since all he said was "partial bowel obstruction or partial ileus" then a few lines down states "partial bowel obstruction or partial ileus"

    Denise Davis RN
    Clinical Documentation Specialist
    Quality Management
    Sonora Regional Medical Center
    1000 Greenley RD Sonora Ca 95370
    209-536-3290
    davisd2@ah.org
  • davisd2davisd2
    opps.....forgot to say that patient is in our facility now for nausea vomiting "probable partial bowel obstruction or partial ileus"

    Denise Davis RN
    Clinical Documentation Specialist
    Quality Management
    Sonora Regional Medical Center
    1000 Greenley RD Sonora Ca 95370
    209-536-3290
    davisd2@ah.org
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