question

lsipos@monument.health

Good morning. Can anyone (coder or otherwise) let me know how they would code a "mechanical THROMBOLYSIS" using a TREROTALA device. The patient had a DVT and the provider is calling it a "mechanical thrombolysis" via the popliteal (NOT thrombectomy) - as from what I can find, the Trerotala device doesn't remove, just breaks up mechanically?

So, does this code to the thrombectomy or a thrombolysis? The coder and another CDI are having a discussion about this and I wanted opinions!


Thanks!

Juli

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......"
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lsipos@monument.health

I am wondering if it is appropriate to query for "the diagnosis related to inpatient acute care and/or continued admission?" I have a patient who came in with stool incontinence and abd pain x5 days ago. Initially the CT was read as an SMA dissection and was admitted inpatient for observation. However on day 1 Radiology discusses the CT with the provider and reads the SMA dissection as stable and present in Feb when he was admitted for a SBO.

So now here we are on day 5 and c-diff, sbo, etct has been ruled out! The incontinence on admit is blamed on a low residue diet, and the patient is eating a regular diet now, and has been for 2 days. AND of course, hasn't had a BM since admit and in fact now they are saying he feels constipated. ALL I am getting in progress notes is "abd pain". NO SBO, nothing else, other than some nausea....

There is no HER medical necessity form scanned as of yet, and no care manager notes....

I want to query the RESIDENTS and ask what the reason is for INPT admit and/ or continued admission. I don't normally do that, but is that ok? It is obvious there is no documented reason for the abd pain as they have done all the tests etc.... they say the SMA dissection is not an acute issue. I am looking at a LOS DRG for abd pain of 2.7 and here we are 5 days later..... And how do I pose that query question???

Thanks!

Juli