Septic Joint
Hi All,
I have a case I am reviewing where the patient came in with septic joints (and sepsis) of the knee and shoulder. The patient is s/p shoulder replacement 3 weeks ago. She fell at home and symptoms progressed after the fall. The ID doc states that the septic shock is 'possibly associated with the left prosthetic shoulder'The attending does not confirm or negate that the septic joint is related to the prosthetic shoulder
We have multiple people looking at the case and everyone is coming to a different conclusion. The coder originally coded this in draft as a complication as is, without query prior to sending it my way for a 2nd level review. The concurrent CDI did not query and did not think one was needed because we are three weeks out from surgery and symptoms started after a fall. I lean toward querying the MD as to whether the septic joint is 2/2 joint prosthesis. I personally don't think you can ignore the fact that the joint was replaced. Septic joints cane happen years after surgery and still be a result of prosthesis. Correct? But I also think the connection should be explicitly stated rather than assumed. The patient does have rheumatoid arthritis as an additional risk factor for septic joints.
I made the recommendation to query yesterday but the CDI was out sick. We had been waiting for the OP note (debridement) and it magically has appeared today. The surgeon states: 'This patient has been admitted to the hospital and over the last 2 days has begun to show worrisome signs of multisystem failure and multisystem sepsis, and severe bacteremia. At this time, the cause is still uncertain.' And then proceeds to remove 40ml of purulent fluid from the knee and debride extensively. Then they dissected the shoulder with finding of copious amounts of straw-colored fluid. He says: "The reverse total shoulder appeared to be stable, in good shape, and there were no signs of actual devitalized tissue. These findings suggested an infectious process only very recently appearing in this joint, probably within the last 48 hours."
Opinions? Is that documentation sufficient to say there is no link or should we still query? Other ideas?
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
I have a case I am reviewing where the patient came in with septic joints (and sepsis) of the knee and shoulder. The patient is s/p shoulder replacement 3 weeks ago. She fell at home and symptoms progressed after the fall. The ID doc states that the septic shock is 'possibly associated with the left prosthetic shoulder'The attending does not confirm or negate that the septic joint is related to the prosthetic shoulder
We have multiple people looking at the case and everyone is coming to a different conclusion. The coder originally coded this in draft as a complication as is, without query prior to sending it my way for a 2nd level review. The concurrent CDI did not query and did not think one was needed because we are three weeks out from surgery and symptoms started after a fall. I lean toward querying the MD as to whether the septic joint is 2/2 joint prosthesis. I personally don't think you can ignore the fact that the joint was replaced. Septic joints cane happen years after surgery and still be a result of prosthesis. Correct? But I also think the connection should be explicitly stated rather than assumed. The patient does have rheumatoid arthritis as an additional risk factor for septic joints.
I made the recommendation to query yesterday but the CDI was out sick. We had been waiting for the OP note (debridement) and it magically has appeared today. The surgeon states: 'This patient has been admitted to the hospital and over the last 2 days has begun to show worrisome signs of multisystem failure and multisystem sepsis, and severe bacteremia. At this time, the cause is still uncertain.' And then proceeds to remove 40ml of purulent fluid from the knee and debride extensively. Then they dissected the shoulder with finding of copious amounts of straw-colored fluid. He says: "The reverse total shoulder appeared to be stable, in good shape, and there were no signs of actual devitalized tissue. These findings suggested an infectious process only very recently appearing in this joint, probably within the last 48 hours."
Opinions? Is that documentation sufficient to say there is no link or should we still query? Other ideas?
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
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
I would either query for the underlying cause of sepsis or if there is a linkage between the sepsis and knee prosthesis and/or shoulder prosthesis. I don't think in this case you can make an assumption. It is alway important to have it clearly documented in the record as this will determine the code assignment for the principal diagnosis.
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.
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
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
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
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.
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
Melissa H. Crigger, RN-BSN, MHA, CCM, CCDS
Carilion Clinic, Roanoke, VA
Clinical Documentation Integrity
Phone: (540) 981-7725
Dorie Douthit RHIT,CCS
AHIMA-Approved ICD-10-CM/PCS Trainer
ddouthit@stmarysathens.org
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
Judy
Judy Riley, RHIT, CCS, CPC
Coding/CDI Manager
LRGHealthcare
Lakes x 3315
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923