minutiae...
As always with CDI, the tiniest variance in terminology matters. I am currently auditing a bunch of Major Joint charts to see if we have room to improve our CC/MCC capture. I am looking at a chart now where the patient has underlying COPD and has an exacerbation post op. The MD states in the D/C summery "She had a chest x-ray which showed some pulmonary edema. The patient was diagnosed with volume overload pulmonary edema and exacerbation of chronic obstructive pulmonary disease."
In your opinion, does the word 'acute' have to be clearly stated in order to code 'acute pulmonary edema'. Or is the fact that this condition developed during the hospitalization allow us to assume it? My gut says that CDI should have clarified but I want to make sure that coding shouldn't have picked it up as is...
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
In your opinion, does the word 'acute' have to be clearly stated in order to code 'acute pulmonary edema'. Or is the fact that this condition developed during the hospitalization allow us to assume it? My gut says that CDI should have clarified but I want to make sure that coding shouldn't have picked it up as is...
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
Comments
Ann
Sent from my iPhone
On Aug 19, 2014, at 4:17 PM, CDI Talk wrote:
As always with CDI, the tiniest variance in terminology matters. I am
currently auditing a bunch of Major Joint charts to see if we have room to
improve our CC/MCC capture. I am looking at a chart now where the patient
has underlying COPD and has an exacerbation post op. The MD states in the
D/C summery “She had a chest x-ray which showed some pulmonary edema. The
patient was diagnosed with volume overload pulmonary edema and exacerbation
of chronic obstructive pulmonary disease.”
In your opinion, does the word ‘acute’ have to be clearly stated in order
to code ‘acute pulmonary edema’. Or is the fact that this condition
developed during the hospitalization allow us to assume it? My gut says
that CDI should have clarified but I want to make sure that coding
shouldn’t have picked it up as is…
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
Claudine Hutchinson RN (CDI)
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
Contestant: "Wood"
Alex Trebek: "Sorry that is not correct, we were looking for woods".
It is the golden rule-he who has the gold makes the rules-Medicare
Charlie Morell
process was managed....diuresis, pulmonary interventions, etc., rather than
it appearing to be a radiological finding that required no intervention.
In the facilities I have worked, I haven't seen it coded to acute w/o a
query or existing documentation.
Cindy Pritchett, RN, BSN, CCDS
MedPartners CDI Consultant
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
a coding auditing consultant we've had in the past) would require the
term acute.
Were there indicators that would support post-op resp insuff? ie, was
the pulm edema a consequence of the surg/anes and the trigger for COPD
exac/impaired resp function.
Don
I believed the coder could apply the label as long as the facts in the medical record lead inexorably to that conclusion. Absent text from the Centers for Medicaid & Medicare Services (CMS) or a CMS-authorized body reading something like “unless a physician has used a particular term, the coder can’t code it; coders can’t use logic to select a code,†the assertion that coders can infer remains valid. The burden,should be on those asserting that coders are forbidden to make an inference. .†Inference is science; assumption is guesswork. I agree that coders shouldn't assume. The difference between an assumption and an inference (or deduction) is data. I assert that coders can rely on data in the record to select a code.
Paul Evans, RHIA, CCDS, CCS, CCS-P
Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com
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Kerry Seekircher, RN, BS, CCDS, CDIP
Clinical 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
I was in a discussion with a group of physicians recently who apparently have some Law background. I explained to them why precise documentation was required for the coders and they claim the Medicare Claims Processing Manual does not indicate that use of The Official ICD-9-CM Guidelines for Coding and Reporting is a condition of payment.
As is the case with their documentation they were trying to muddy the waters...