POA status

Hi all,
I have a situation that seems to just not want to go away so I believe that I could use more opinions on the matter. We have a case where a 19 year old is involved in a MVC with significant injuries including to the head. On admission he has a IVH and frontal contusion but the CT scan does not reveal anything else. The next day, he has changes in mental status, is rescanned, and they note he has a 'new SAH'. This was coded as POA (N) making it a Hospital Acquired Injury. Obviously the injury was related to the MVC and did not occur in house but this is how a POA(N) ICH is tagged. The coders are saying that the POA status has to be (N) because of the verbiage of 'new'. Quality is saying that POA should be (Y).

Thoughts?

Thanks in advance.

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

  • edited March 2016
    Maybe query for "newly discovered rt original injury or "evolving""?

    Sent from my iPhone

    On Apr 25, 2014, at 8:44 AM, CDI Talk wrote:

    Hi all,

    I have a situation that seems to just not want to go away so I believe that
    I could use more opinions on the matter. We have a case where a 19 year old
    is involved in a MVC with significant injuries including to the head. On
    admission he has a IVH and frontal contusion but the CT scan does not
    reveal anything else. The next day, he has changes in mental status, is
    rescanned, and they note he has a ‘new SAH’. This was coded as POA (N)
    making it a Hospital Acquired Injury. Obviously the injury was related to
    the MVC and did not occur in house but this is how a POA(N) ICH is tagged.
    The coders are saying that the POA status has to be (N) because of the
    verbiage of ‘new’. Quality is saying that POA should be (Y).



    Thoughts?



    Thanks in advance.



    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



  • edited March 2016
    Hi Katy!
    I believe you can always query the physician for his clinical judgement as to determine whether a condition was/was not present on admission.  The POA guidelines state on page 97 paragraph #4 that "these guidelines are not a substitute for provider's clinical judgment as to the determination of whether a condition was/was not present on admission.
     
    I agree with you though....think it was POA.
     
    Jolene File,RHIT,CCS,CPC-H,CCDS
    Documentation Improvement Specialist-Coder
    Hays Medical Center
    jolene.file@haysmed.com

  • edited March 2016
    I would agree that this was likely poa -would it be appropriate in this case for you to ask for language clarifying evolving?
    Kerry

    Kerry Seekircher, RN, CCDS, CDIP
    Documentation Specialist Supervisor
    Northern Westchester Hospital
    400 East Main Street
    Mount Kisco, NY 10549
    Email: kseekircher@nwhc.net
    Phone: 914-666-1243
    Fax: 914-666-1013




    ________________________________
  • edited March 2016
    Of course I advocate for a query in this case. I think that if the coder was comfortable coding the injury as POA(Y) that is ok, but I think that if we were not comfortable with this, a query should have been generated. I think before coding a HAC or HAI, we should be especially diligent to make sure we are 100% sure of the status.
    I do find the formulation of a query a bit difficult in this case as far as wording. What do you think about the following.

    Could you please clarify whether the subarachnoid hemorrhage likely is:

    1. Present on admission but unidentified in initial CT scan

    2. Not present on admission, developing during hospitalization

    3. Unable to determine

    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

  • Maybe add to #2 "but suspected due to original/initial injury" (or
    something to that effect)?



    Claudine Hutchinson RN (CDI)

    The Children's Hospital at Saint Francis

    chutchinson@saintfrancis.com



    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, April 25, 2014 10:01 AM
    To: Hutchinson, Claudine
    Subject: RE:[cdi_talk] POA status



    Of course I advocate for a query in this case. I think that if the coder
    was comfortable coding the injury as POA(Y) that is ok, but I think that
    if we were not comfortable with this, a query should have been
    generated. I think before coding a HAC or HAI, we should be especially
    diligent to make sure we are 100% sure of the status.

    I do find the formulation of a query a bit difficult in this case as far
    as wording. What do you think about the following.



    Could you please clarify whether the subarachnoid hemorrhage likely is:

    1. Present on admission but unidentified in initial CT scan

    2. Not present on admission, developing during hospitalization

    3. Unable to determine



    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



    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, April 25, 2014 6:55 AM
    To: Kathryn Good
    Subject: RE:[cdi_talk] POA status



    I would agree that this was likely poa -would it be appropriate in this
    case for you to ask for language clarifying evolving?

    Kerry



    Kerry Seekircher, RN, CCDS, CDIP

    Documentation Specialist Supervisor

    Northern Westchester Hospital

    400 East Main Street

    Mount Kisco, NY 10549

    Email: kseekircher@nwhc.net

    Phone: 914-666-1243

    Fax: 914-666-1013









    ________________________________

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, April 25, 2014 10:43 AM
    To: Seekircher, Kerry
    Subject: [cdi_talk] POA status



    Hi all,

    I have a situation that seems to just not want to go away so I believe
    that I could use more opinions on the matter. We have a case where a 19
    year old is involved in a MVC with significant injuries including to the
    head. On admission he has a IVH and frontal contusion but the CT scan
    does not reveal anything else. The next day, he has changes in mental
    status, is rescanned, and they note he has a 'new SAH'. This was coded
    as POA (N) making it a Hospital Acquired Injury. Obviously the injury
    was related to the MVC and did not occur in house but this is how a
    POA(N) ICH is tagged. The coders are saying that the POA status has to
    be (N) because of the verbiage of 'new'. Quality is saying that POA
    should be (Y).



    Thoughts?



    Thanks in advance.



    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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    ----------------------------------------------------------------------



    Saint Francis Health System intends this email only for the use of the person to whom it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If you have received this email in error, you are hereby notified that we do not consent to any reading, dissemination, distribution, or copying of this email and request you notify the sender immediately and destroy this transmission. Violators may be prosecuted under Federal law.
  • Yes, I agree this is more clear. But would still result in a POA(N), correct?

    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

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, April 25, 2014 7:04 AM
    To: Kathryn Good
    Subject: RE: [cdi_talk] POA status

    Maybe add to #2 "but suspected due to original/initial injury" (or something to that effect)?

    Claudine Hutchinson RN (CDI)
    The Children's Hospital at Saint Francis
    chutchinson@saintfrancis.com

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, April 25, 2014 10:01 AM
    To: Hutchinson, Claudine
    Subject: RE:[cdi_talk] POA status

    Of course I advocate for a query in this case. I think that if the coder was comfortable coding the injury as POA(Y) that is ok, but I think that if we were not comfortable with this, a query should have been generated. I think before coding a HAC or HAI, we should be especially diligent to make sure we are 100% sure of the status.
    I do find the formulation of a query a bit difficult in this case as far as wording. What do you think about the following.

    Could you please clarify whether the subarachnoid hemorrhage likely is:

    1. Present on admission but unidentified in initial CT scan

    2. Not present on admission, developing during hospitalization

    3. Unable to determine

    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

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, April 25, 2014 6:55 AM
    To: Kathryn Good
    Subject: RE:[cdi_talk] POA status

    I would agree that this was likely poa -would it be appropriate in this case for you to ask for language clarifying evolving?
    Kerry

    Kerry Seekircher, RN, CCDS, CDIP
    Documentation Specialist Supervisor
    Northern Westchester Hospital
    400 East Main Street
    Mount Kisco, NY 10549
    Email: kseekircher@nwhc.net
    Phone: 914-666-1243
    Fax: 914-666-1013




    ________________________________
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, April 25, 2014 10:43 AM
    To: Seekircher, Kerry
    Subject: [cdi_talk] POA status

    Hi all,
    I have a situation that seems to just not want to go away so I believe that I could use more opinions on the matter. We have a case where a 19 year old is involved in a MVC with significant injuries including to the head. On admission he has a IVH and frontal contusion but the CT scan does not reveal anything else. The next day, he has changes in mental status, is rescanned, and they note he has a 'new SAH'. This was coded as POA (N) making it a Hospital Acquired Injury. Obviously the injury was related to the MVC and did not occur in house but this is how a POA(N) ICH is tagged. The coders are saying that the POA status has to be (N) because of the verbiage of 'new'. Quality is saying that POA should be (Y).

    Thoughts?

    Thanks in advance.

    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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    ________________________________
    Note:
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    Any views expressed in this message are those of the individual sender, except where the message states otherwise and the sender is authorized to state them to be the views of any such entity.



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    Saint Francis Health System intends this email only for the use of the person to whom it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If you have received this email in error, you are hereby notified that we do not consent to any reading, dissemination, distribution, or copying of this email and request you notify the sender immediately and destroy this transmission. Violators may be prosecuted under Federal law.




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  • My version:

    s/p MVC.
    IVH and frontal contusion on intial Head CT.
    SAH noted on Head CT dated_______.
    Based on your clinical judgement , please document whether SAH was:

    - Evolving/ Present on Admission
    - New finding / Not Present on Admission
    - Unable to determine
    - Other_____________

    GL



    On 4/25/14, CDI Talk wrote:
    > Of course I advocate for a query in this case. I think that if the coder was
    > comfortable coding the injury as POA(Y) that is ok, but I think that if we
    > were not comfortable with this, a query should have been generated. I think
    > before coding a HAC or HAI, we should be especially diligent to make sure we
    > are 100% sure of the status.
    > I do find the formulation of a query a bit difficult in this case as far as
    > wording. What do you think about the following.
    >
    > Could you please clarify whether the subarachnoid hemorrhage likely is:
    >
    > 1. Present on admission but unidentified in initial CT scan
    >
    > 2. Not present on admission, developing during hospitalization
    >
    > 3. Unable to determine
    >
    > 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
    >
    > From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    > Sent: Friday, April 25, 2014 6:55 AM
    > To: Kathryn Good
    > Subject: RE:[cdi_talk] POA status
    >
    > I would agree that this was likely poa -would it be appropriate in this case
    > for you to ask for language clarifying evolving?
    > Kerry
    >
    > Kerry Seekircher, RN, CCDS, CDIP
    > Documentation Specialist Supervisor
    > Northern Westchester Hospital
    > 400 East Main Street
    > Mount Kisco, NY 10549
    > Email: kseekircher@nwhc.net
    > Phone: 914-666-1243
    > Fax: 914-666-1013
    >
    >
    >
    >
    > ________________________________
    > From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    > Sent: Friday, April 25, 2014 10:43 AM
    > To: Seekircher, Kerry
    > Subject: [cdi_talk] POA status
    >
    > Hi all,
    > I have a situation that seems to just not want to go away so I believe that
    > I could use more opinions on the matter. We have a case where a 19 year old
    > is involved in a MVC with significant injuries including to the head. On
    > admission he has a IVH and frontal contusion but the CT scan does not reveal
    > anything else. The next day, he has changes in mental status, is rescanned,
    > and they note he has a 'new SAH'. This was coded as POA (N) making it a
    > Hospital Acquired Injury. Obviously the injury was related to the MVC and
    > did not occur in house but this is how a POA(N) ICH is tagged. The coders
    > are saying that the POA status has to be (N) because of the verbiage of
    > 'new'. Quality is saying that POA should be (Y).
    >
    > Thoughts?
    >
    > Thanks in advance.
    >
    > 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
    >
    >
    >
    >
    > ---
    >
    > CDI Talk is offered for networking purposes. For official rules and
    > regulations related to documentation and coding, please refer to your
    > regulatory source.
    >
    >
    >
    > You are receiving this message as a member of CDI Talk as:
    > kseekircher@nwhc.net
    >
    > If you would like to be removed from CDI Talk, please send a blank email to
    >
    > leave-cdi_talk-20097959.d65e69fc5d7027e8a40023ced48ccf9e@hcprotalk.com
    >
    > ---
    >
    > Copyright 2013
    >
    > HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
    >
    > ________________________________
    > Note:
    > This message is for the named person's use only. It may contain
    > confidential, proprietary or legally privileged information. No
    > confidentiality or privilege is waived or lost by any mistransmission. If
    > you receive this message in error, please immediately delete it and all
    > copies of it from your system, destroy any hard copies of it and notify the
    > sender. You must not, directly or indirectly, use, disclose, distribute,
    > print, or copy any part of this message if you are not the intended
    > recipient. STELLARIS HEALTH NETWORK and any of its subsidiaries each reserve
    > the right to monitor all e-mail communications through its networks.
    >
    > Any views expressed in this message are those of the individual sender,
    > except where the message states otherwise and the sender is authorized to
    > state them to be the views of any such entity.
    >
    >
    >
    > ---
    >
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    > regulations related to documentation and coding, please refer to your
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    >
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    >
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    > Copyright 2013
    >
    > HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
    >
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  • Very good concise query. In my opinion, either query would work. You could also verbal, so the physician understand the reason behind the query.

    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.

    ----- Original Message -----
    From: "CDI Talk"
    To: "jolene file"
    Sent: Friday, April 25, 2014 10:19:19 AM
    Subject: Re: [cdi_talk] POA status

    My version:

    s/p MVC.
    IVH and frontal contusion on intial Head CT.
    SAH noted on Head CT dated_______.
    Based on your clinical judgement , please document whether SAH was:

    - Evolving/ Present on Admission
    - New finding / Not Present on Admission
    - Unable to determine
    - Other_____________

    GL



    On 4/25/14, CDI Talk wrote:
    > Of course I advocate for a query in this case. I think that if the coder was
    > comfortable coding the injury as POA(Y) that is ok, but I think that if we
    > were not comfortable with this, a query should have been generated. I think
    > before coding a HAC or HAI, we should be especially diligent to make sure we
    > are 100% sure of the status.
    > I do find the formulation of a query a bit difficult in this case as far as
    > wording. What do you think about the following.
    >
    > Could you please clarify whether the subarachnoid hemorrhage likely is:
    >
    > 1. Present on admission but unidentified in initial CT scan
    >
    > 2. Not present on admission, developing during hospitalization
    >
    > 3. Unable to determine
    >
    > 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
    >
    > From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    > Sent: Friday, April 25, 2014 6:55 AM
    > To: Kathryn Good
    > Subject: RE:[cdi_talk] POA status
    >
    > I would agree that this was likely poa -would it be appropriate in this case
    > for you to ask for language clarifying evolving?
    > Kerry
    >
    > Kerry Seekircher, RN, CCDS, CDIP
    > Documentation Specialist Supervisor
    > Northern Westchester Hospital
    > 400 East Main Street
    > Mount Kisco, NY 10549
    > Email: kseekircher@nwhc.net
    > Phone: 914-666-1243
    > Fax: 914-666-1013
    >
    >
    >
    >
    > ________________________________
    > From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    > Sent: Friday, April 25, 2014 10:43 AM
    > To: Seekircher, Kerry
    > Subject: [cdi_talk] POA status
    >
    > Hi all,
    > I have a situation that seems to just not want to go away so I believe that
    > I could use more opinions on the matter. We have a case where a 19 year old
    > is involved in a MVC with significant injuries including to the head. On
    > admission he has a IVH and frontal contusion but the CT scan does not reveal
    > anything else. The next day, he has changes in mental status, is rescanned,
    > and they note he has a 'new SAH'. This was coded as POA (N) making it a
    > Hospital Acquired Injury. Obviously the injury was related to the MVC and
    > did not occur in house but this is how a POA(N) ICH is tagged. The coders
    > are saying that the POA status has to be (N) because of the verbiage of
    > 'new'. Quality is saying that POA should be (Y).
    >
    > Thoughts?
    >
    > Thanks in advance.
    >
    > 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
    >
    >
    >
    >
    > ---
    >
    > CDI Talk is offered for networking purposes. For official rules and
    > regulations related to documentation and coding, please refer to your
    > regulatory source.
    >
    >
    >
    > You are receiving this message as a member of CDI Talk as:
    > kseekircher@nwhc.net
    >
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  • Katy-
    I also think it might help to speak to the MD to explain the circumstances of the query, as he/she will probably think (as do you) that the answer is obvious. At least that way, you maintain a good relationship and have the opportunity to explain the importance of making sure the poa is coded correctly.
    If you have to do an email query-you might have better luck with the way the query was worded by GL-
    - Evolving/ Present on Admission
    - New finding / Not Present on Admission
    - Unable to determine
    - Other_____________

    Kerry

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, April 25, 2014 11:26 AM
    To: Seekircher, Kerry
    Subject: Re: [cdi_talk] POA status

    Very good concise query. In my opinion, either query would work. You could also verbal, so the physician understand the reason behind the query.

    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.

    ----- Original Message -----
    From: "CDI Talk"
    To: "jolene file"
    Sent: Friday, April 25, 2014 10:19:19 AM
    Subject: Re: [cdi_talk] POA status

    My version:

    s/p MVC.
    IVH and frontal contusion on intial Head CT.
    SAH noted on Head CT dated_______.
    Based on your clinical judgement , please document whether SAH was:


    GL



    On 4/25/14, CDI Talk wrote:
    > Of course I advocate for a query in this case. I think that if the coder was
    > comfortable coding the injury as POA(Y) that is ok, but I think that if we
    > were not comfortable with this, a query should have been generated. I think
    > before coding a HAC or HAI, we should be especially diligent to make sure we
    > are 100% sure of the status.
    > I do find the formulation of a query a bit difficult in this case as far as
    > wording. What do you think about the following.
    >
    > Could you please clarify whether the subarachnoid hemorrhage likely is:
    >
    > 1. Present on admission but unidentified in initial CT scan
    >
    > 2. Not present on admission, developing during hospitalization
    >
    > 3. Unable to determine
    >
    > 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
    >
    > From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    > Sent: Friday, April 25, 2014 6:55 AM
    > To: Kathryn Good
    > Subject: RE:[cdi_talk] POA status
    >
    > I would agree that this was likely poa -would it be appropriate in this case
    > for you to ask for language clarifying evolving?
    > Kerry
    >
    > Kerry Seekircher, RN, CCDS, CDIP
    > Documentation Specialist Supervisor
    > Northern Westchester Hospital
    > 400 East Main Street
    > Mount Kisco, NY 10549
    > Email: kseekircher@nwhc.net
    > Phone: 914-666-1243
    > Fax: 914-666-1013
    >
    >
    >
    >
    > ________________________________
    > From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    > Sent: Friday, April 25, 2014 10:43 AM
    > To: Seekircher, Kerry
    > Subject: [cdi_talk] POA status
    >
    > Hi all,
    > I have a situation that seems to just not want to go away so I believe that
    > I could use more opinions on the matter. We have a case where a 19 year old
    > is involved in a MVC with significant injuries including to the head. On
    > admission he has a IVH and frontal contusion but the CT scan does not reveal
    > anything else. The next day, he has changes in mental status, is rescanned,
    > and they note he has a 'new SAH'. This was coded as POA (N) making it a
    > Hospital Acquired Injury. Obviously the injury was related to the MVC and
    > did not occur in house but this is how a POA(N) ICH is tagged. The coders
    > are saying that the POA status has to be (N) because of the verbiage of
    > 'new'. Quality is saying that POA should be (Y).
    >
    > Thoughts?
    >
    > Thanks in advance.
    >
    > 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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    > regulatory source.
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    >
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  • Thanks everyone! I think it helps the coders understand our rationale when unbiased individuals, from other hospitals, agree with our opinion. It takes a village... :)

    See y'all TOMORROW!!! Can't believe the conference is finally here! :)-V


    Vicki S. Davis, RN CDS
    Clinical Documentation Improvement Manager
    Health Information Management Department
    Cone Health at Alamance Regional
    Office (336) 586-3765
    Ascom Mobile (336) 586-4191
    Fax (336) 538-7428
    vdavis2@armc.com



    "Leadership is solving problems. The day soldiers stop bringing you their problems is the day you have stopped leading them. They have either lost confidence that you can help or concluded you do not care. Either case is a failure of leadership."- Colin Powell







    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, April 25, 2014 11:39 AM
    To: Davis, Vicki S.
    Subject: RE: [cdi_talk] POA status

    Katy-
    I also think it might help to speak to the MD to explain the circumstances of the query, as he/she will probably think (as do you) that the answer is obvious. At least that way, you maintain a good relationship and have the opportunity to explain the importance of making sure the poa is coded correctly.
    If you have to do an email query-you might have better luck with the way the query was worded by GL-
    - Evolving/ Present on Admission
    - New finding / Not Present on Admission
    - Unable to determine
    - Other_____________

    Kerry

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, April 25, 2014 11:26 AM
    To: Seekircher, Kerry
    Subject: Re: [cdi_talk] POA status

    Very good concise query. In my opinion, either query would work. You could also verbal, so the physician understand the reason behind the query.

    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.

    ----- Original Message -----
    From: "CDI Talk"
    To: "jolene file"
    Sent: Friday, April 25, 2014 10:19:19 AM
    Subject: Re: [cdi_talk] POA status

    My version:

    s/p MVC.
    IVH and frontal contusion on intial Head CT.
    SAH noted on Head CT dated_______.
    Based on your clinical judgement , please document whether SAH was:


    GL



    On 4/25/14, CDI Talk wrote:
    > Of course I advocate for a query in this case. I think that if the coder was
    > comfortable coding the injury as POA(Y) that is ok, but I think that if we
    > were not comfortable with this, a query should have been generated. I think
    > before coding a HAC or HAI, we should be especially diligent to make sure we
    > are 100% sure of the status.
    > I do find the formulation of a query a bit difficult in this case as far as
    > wording. What do you think about the following.
    >
    > Could you please clarify whether the subarachnoid hemorrhage likely is:
    >
    > 1. Present on admission but unidentified in initial CT scan
    >
    > 2. Not present on admission, developing during hospitalization
    >
    > 3. Unable to determine
    >
    > 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
    >
    > From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    > Sent: Friday, April 25, 2014 6:55 AM
    > To: Kathryn Good
    > Subject: RE:[cdi_talk] POA status
    >
    > I would agree that this was likely poa -would it be appropriate in this case
    > for you to ask for language clarifying evolving?
    > Kerry
    >
    > Kerry Seekircher, RN, CCDS, CDIP
    > Documentation Specialist Supervisor
    > Northern Westchester Hospital
    > 400 East Main Street
    > Mount Kisco, NY 10549
    > Email: kseekircher@nwhc.net
    > Phone: 914-666-1243
    > Fax: 914-666-1013
    >
    >
    >
    >
    > ________________________________
    > From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    > Sent: Friday, April 25, 2014 10:43 AM
    > To: Seekircher, Kerry
    > Subject: [cdi_talk] POA status
    >
    > Hi all,
    > I have a situation that seems to just not want to go away so I believe that
    > I could use more opinions on the matter. We have a case where a 19 year old
    > is involved in a MVC with significant injuries including to the head. On
    > admission he has a IVH and frontal contusion but the CT scan does not reveal
    > anything else. The next day, he has changes in mental status, is rescanned,
    > and they note he has a 'new SAH'. This was coded as POA (N) making it a
    > Hospital Acquired Injury. Obviously the injury was related to the MVC and
    > did not occur in house but this is how a POA(N) ICH is tagged. The coders
    > are saying that the POA status has to be (N) because of the verbiage of
    > 'new'. Quality is saying that POA should be (Y).
    >
    > Thoughts?
    >
    > Thanks in advance.
    >
    > 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
    >
    >
    >
    >
    > ---
    >
    > CDI Talk is offered for networking purposes. For official rules and
    > regulations related to documentation and coding, please refer to your
    > regulatory source.
    >
    >
    >
    > You are receiving this message as a member of CDI Talk as:
    > kseekircher@nwhc.net
    >
    > If you would like to be removed from CDI Talk, please send a blank email to
    >
    > leave-cdi_talk-20097959.d65e69fc5d7027e8a40023ced48ccf9e@hcprotalk.com
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    >
    > Copyright 2013
    >
    > HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
    >
    > ________________________________
    > Note:
    > This message is for the named person's use only. It may contain
    > confidential, proprietary or legally privileged information. No
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    > sender. You must not, directly or indirectly, use, disclose, distribute,
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    > recipient. STELLARIS HEALTH NETWORK and any of its subsidiaries each reserve
    > the right to monitor all e-mail communications through its networks.
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    > except where the message states otherwise and the sender is authorized to
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  • I agree with Karen that it would a progression with POA of Y. CC 1st Qtr 2013 page 18 might be used to support this.

    Also interested in others views.

    Thanks,

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, January 19, 2016 3:26 PM
    To: Salinas, Sharon
    Subject: RE:[cdi_talk] POA status

    Katy, I'm thinking it would be a progression, similar to a pressure ulcer stage II to III.. and POA. Be interesting to see how others view this.

    Thanks Karen

    Karen Bridgeman MSN, RN, CCDS
    CDI Educator
    Clinical Documentation Integrity
    Medical University of South Carolina
    Phone: 843.876.0333
    Email: bridgema@musc.edu

    Confidentiality Notice: If you have received this communication in error, please notify me immediately. The documents accompanying this facsimile/electronic transmission contain confidential information intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure. If the reader of this message is not the intended recipient, or an employee responsible for delivering the message to the intended recipient, you are hereby notified that any disclosure, dissemination, distribution, or copying of this communication is strictly prohibited.

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, January 19, 2016 5:57 PM
    To: Bridgeman, Karen
    Subject: [cdi_talk] POA status



    I have a patient that had moderate malnutrition on admission which progressed to severe (complete duodenal obstruction d/t cancer). Patient was on TPN and eventually died during this admission.
    In your assessment, does this fall into the category of an exacerbation like CHF where this would be POA(N) or in progression of renal failure staging where it would be POA(Y)?

    Any relevant guidance would be appreciated.

    Thanks!

    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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  • Yup. This is the coding clinic I currently have sitting in my email to support it as POA(Y). I agree with both you and Karen that this is how I see it. Wanted to make sure I wasn't headed off track :)

    Thanks so much!

    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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