hospital policy for postoperative respiratory failure

amkelly3@partners.orgamkelly3@partners.org
in CDI Talk Archive
Does anyone have a hospital policy that describes the clinical characteristics of a particular diagnosis? If so, does coding have a parallel policy that directs the coders to code according to the hospital policy?
Thanks in advance for your thoughts.

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    My 2 cents on this: We do not (yet) have facility definitions though we have discussed creating them for those diagnoses that are frequently denied (sepsis, encephalopathy, renal failure, respiratory failure). I think hospital definitions are helpful in these circumstances because they give all parties guidance as to clinical indicators of the diagnoses and something on which to base queries and/or appeals.

    As far as a coding policy, I am not sure exactly what you have in mind, but hospital policy cannot trump coding guidelines/clinics/etc. For instance, you could not have a coding policy that stated that if the physician documents 'midline shift' we should code brain compression. I would also argue you cannot do the reverse and implement a policy that states that you only code a physician generated diagnosis if certain clinical criteria are met. These are opportunities for queries not policies.

    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


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