Post Discharge Results

mowsleymowsley
in CDI Talk Archive
Hello- I am currently reviewing a RAC pre-payment account that presented with Syncope, and was found to be hypotensive and in Atrial Fibrillation in the 60's. This patient was nine days post TEE/Cardioversion. The patient received fluid resuscitation and an increase in his midorine, after which he was no longer orthostatic. Per the discharge summary, the physician documented "near syncope likely related to hypotension". The patient was discharged on a holter monitor.
The holter monitor results are now back and showing probable Sick Sinus Syndrome. I would like to query retrospectively to ask if this was anyway related to the syncope in which the patient presented with. I was hoping to get input as to how others are querying retrospectively when results are noted after discharge. Thanks!

Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    We routinely query post discharge using the same methods, forms, and queries as when we perform a concurrent review. The process is the same for CDI: however, the MD response rate is not as robust as some are less willing to respond to a query post D/C.



    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


  • jolene.filejolene.file
    edited April 2016
    Hi!
    I would be reluctant to query for the diagnosis from the holter as the holter monitor was not used in the hospital setting, if I understand correctly. It would appear to me with the info that you have shared that the p. diagnosis would be the orthostatic hypotension. My thought is that if the pt. was diagnosed with SSS that they would probably have put in the pacemaker on that hospital stay.

    Just my opinion. The Coder usually does the retrospective query but in the same manner.

    Jolene File,RHIT,CCS,CPC-H,CCDS
    Documentation Improvement Specialist-Coder
    Hays Medical Center
    jolene.file@haysmed.com

  • kerryseekircherkerryseekircher
    edited April 2016
    Agreed-As the testing was completed outpt, it would not be appropriate to query in this case. The pdx will ultimately be what the physician felt the underlying cause of the syncope was at the time of discharge. If he/she noted it was due to hypotension, you are likely stuck there : (
    If he/she had not specified what the syncope was due to, a query might have been appropriate to determine if it was due to an arrhythmia or another underlying cause.
    Thanks,
    Kerry

    Kerry Seekircher, RN BSN, 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


Sign In or Register to comment.