Observation to Inpatient
I could use some clarification. For patients that move from Observation to Inpatient, am I correct in my understanding that it should be the reason for INPATIENT admission that should be the Pdx?
We just had a chart of a lady who suffered a minor trip and fall that exacerbated her pre-existing back pain and was admitted to OBS status. The next day she developed renal failure and was admitted to IP for management of this. Shouldn't this ARF then be the Pdx?
Of course the contributing issue is that the MD never states that the ARF is the reason for IP admission, I know this because we have a consult from EHR (who we consult with for status determination) and the MD from EHR says that this is the reason for admit but that consult is not codeable.
I want to make sure my understanding of how it should be coded is accurate before I address the documentation issue that needs to be corrected in order to support the accurate coding.
I hope that makes sense ;-)
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
We just had a chart of a lady who suffered a minor trip and fall that exacerbated her pre-existing back pain and was admitted to OBS status. The next day she developed renal failure and was admitted to IP for management of this. Shouldn't this ARF then be the Pdx?
Of course the contributing issue is that the MD never states that the ARF is the reason for IP admission, I know this because we have a consult from EHR (who we consult with for status determination) and the MD from EHR says that this is the reason for admit but that consult is not codeable.
I want to make sure my understanding of how it should be coded is accurate before I address the documentation issue that needs to be corrected in order to support the accurate coding.
I hope that makes sense ;-)
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