perioperative stroke

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
If we have a 'perioperative' nonhemorrhagic stroke documented, do you need to query for complication or does this automatically lead to the iatrogenic CVA code? Also, would you query for ischemic? Anything I am missing here? First for me...


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

  • catladyrncatladyrn
    edited April 2016
    I would query. The fact that it happened during surgery doesn't automatically mean it was the surgeon's fault; the patient could have been medically fragile. Not to mention that you still have to have a documented link between the procedure and the outcome to code it as a complication. CC 1Q2005 says with regard to iatrogenic CVA, "Documentation should clearly specify the cause-and-effect relationship between the medical intervention and the cerebrovascular accident in order to assign this code."

    Renee

    Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
    Director, Clinical Documentation, Core Measures and Outcomes
    Tanner Health System
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