help!
Good afternoon. Can you please help? Spoke with the head coder, and we are both in a quandary as to how to take this/code this! 
-10/22 Patient admit SSO " AMS blamed on/ due to fent patch. (NO other acute issues, BC drawn) all hx issues stable.
-10/24 Changed to inpt for "Bacteremia". No s/s of infection and no VS / WBC / imaging to lead to conclusion of sepsis. Treated with Zosyn UNTIL second BC comes back negative. (AMS resolved at this point).
-First BC suspicious for contaminant and after study, and eventual documentation with support of Infectious disease provider RULE OUT BACTERMIA stating it was a contaminant.
-So, here we have pt admit inpt for ONLY diagnosis of BACTERMIA subsequently ruled out. No other acute issues, no tx or monitoring other than the Zosyn stopped x2 days ago after issue ruled out. Today he is supposed to go back to NH.
HOW DO YOU CODE the BACTEREMIA as PDX if after study it is ruled out? What would my PDX be?? The coder even thought of the V code V7189 but thought Medicare would be all over that.
Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
755-8426 (work)
786-2677 (cell)
"No Limit to Better......"
[CCDS_pin_1inch]
-10/22 Patient admit SSO " AMS blamed on/ due to fent patch. (NO other acute issues, BC drawn) all hx issues stable.
-10/24 Changed to inpt for "Bacteremia". No s/s of infection and no VS / WBC / imaging to lead to conclusion of sepsis. Treated with Zosyn UNTIL second BC comes back negative. (AMS resolved at this point).
-First BC suspicious for contaminant and after study, and eventual documentation with support of Infectious disease provider RULE OUT BACTERMIA stating it was a contaminant.
-So, here we have pt admit inpt for ONLY diagnosis of BACTERMIA subsequently ruled out. No other acute issues, no tx or monitoring other than the Zosyn stopped x2 days ago after issue ruled out. Today he is supposed to go back to NH.
HOW DO YOU CODE the BACTEREMIA as PDX if after study it is ruled out? What would my PDX be?? The coder even thought of the V code V7189 but thought Medicare would be all over that.
Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
755-8426 (work)
786-2677 (cell)
"No Limit to Better......"
[CCDS_pin_1inch]