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

Comments

  • edited April 2016
    I always query for ACUTE.
    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
  • I would query for acuity of pulm edema. Never assume J

    Claudine Hutchinson RN (CDI)
  • Thanks Claudine and Ann ☺

    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
  • I think of it like the game of jeopardy (ironic-huh?)

    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
  • edited April 2016
    I would query vs assuming. I would also want to know how the disease
    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
  • They did treat with diuretics so I do think coding is justified (assuming a query was placed/answered).

    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 April 2016
    Agreed, our coding staff (as well as both a consultant we work with and
    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 agree that coders cannot diagnose a patient. Can a coder draw obvious deductions from the medical record? If a medical record sufficiently describes a diagnosis without the word (Acute)actually appearing,I think it would be the coder’s job to label it.
    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.
  • The coding and compliance guidelines, Coding Clinic, AHA, CMS, all repeatedly and clearly state that explicit physician documentation of the exact disease process is the basis for coding...the basis for code assignment is this documentation and there are no exceptions.

    Paul Evans, RHIA, CCDS, CCS, CCS-P
  • edited April 2016
    I agree, Paul, the coder is not to make any assumptions.

    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.
  • edited April 2016
    Agree with previous responses-While Coders often are aware that a diagnosis is present; they are not allowed to connect the dots or make assumptions regardless of how evident the diagnosis may seem.

    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 agree with all of you! I am on your side with this after all its what I currently do for a living. I did not articulate this on my prior post...

    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...
  • Oh phone. Those docs are misinformed
  • edited April 2016
    try billing without them.
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