wheelchair bound Query?

ggoodman@virginiahospitalcenter.comggoodman@virginiahospitalcenter.com
edited April 2016 in CDI Talk Archive
Hi everyone I am reviewing a chart where a note mentions pt has MS and is wheelchair bound.
Would this be a good opportunity to Query and see if pt has hemiparesis/hemiplegia, paraparesis/paraplegia, etc.
Or is the current documentation enough???
I've never queried for the reason for the wheelchair dependency before and wonder if I should...

Thanks!
Greta


Comments

  • cnolan@swgeneral.comcnolan@swgeneral.com
    edited April 2016
    JA Thomas encourages clarification for "Functional Quadriplegia" if appropriate.
    See attached; hope it helps.

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Yes, I think this would be a good time to query. I was also wondering if a specified myopathy might give you a CC as well but I think the most appropriate code would probably be the inflammatory and immune myopathies code 359.97 would probably be the best fit and it is not a CC. I am on 100% sure on that though, I would need to brush up on the MS disease process to be 100% certain on that one...

    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

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    If this patient is only wheelchair bound and is using their upper extremities to manage the wheelchair I would not query for functional quad. My understanding is that FQ indicates quadriplegia without spinal cord injury and this sound more like paraplegia without spinal cord injury...

    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

  • cnolan@swgeneral.comcnolan@swgeneral.com
    edited April 2016
    As I stated IF APPROPRIATE!

  • kerryseekircherkerryseekircher
    edited April 2016
    I vote for wheelchair bound being a cc on its own as it clearly indicates increased resources! :)
    I'm in agreement that in order to query for FQ, the pt would need to show evidence of quadriplegia without spinal cord injury. Sometimes, it's hard to tell if nursing documentation is not thorough. I sometimes wish we could assess the pts before sending out queries!
    Thanks,
    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
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    I see that. I did not mean to offend. There would be circumstances where a patient with terminal MS may meet criteria of FQ but in the specific case that Greta presented I do not believe this would apply unless the patient is not managing the wheelchair themselves or is using an electric wheelchair with minimal movement of the upper extremities.

    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
  • ggoodman@virginiahospitalcenter.comggoodman@virginiahospitalcenter.com
    edited April 2016
    Wow-Thanks for all the responses!
    Greta
    :)




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