RE: [EXTERNAL] Would you code 427.5?
If it’s only happened one time during the course of the stay I would question the clinical significance and would be a bit nervous about it being the only MCC on a chart. I would also ask the provider if their workup revealed an underlying cause (complication of anesthesia?). It also appears the patient has some underlying cardiac issues related to the medications they are on (hypertension vs. heart failure?). I guess for me I’d be looking for the why of the pause and if it’s significant or not.
I would also not want to code 427.5 (cardiac arrest) unless a code occurred and interventions were made at that time. There is a big difference between a “pause” and an arrest, and in this case it sounds like the patient spontaneously returned to their baseline rhythm. Maybe 427.81 (Sinoatrial Node Dysfunction) but that will depend on the workup which may not occur during the hospital stay.
I will definitely look forward to hearing more thoughts on this one.
Robert
Robert S. Hodges MSN, BSN, RN, CCDS
Clinical Documentation Improvement Specialist
Secretary, Nursing Professional Standards Board
Aleda E. Lutz VA Medical Center
1500 Weiss Street, ATTN PAS-136
Saginaw MI 48602
989-497-2500 x13101
Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
I would also not want to code 427.5 (cardiac arrest) unless a code occurred and interventions were made at that time. There is a big difference between a “pause” and an arrest, and in this case it sounds like the patient spontaneously returned to their baseline rhythm. Maybe 427.81 (Sinoatrial Node Dysfunction) but that will depend on the workup which may not occur during the hospital stay.
I will definitely look forward to hearing more thoughts on this one.
Robert
Robert S. Hodges MSN, BSN, RN, CCDS
Clinical Documentation Improvement Specialist
Secretary, Nursing Professional Standards Board
Aleda E. Lutz VA Medical Center
1500 Weiss Street, ATTN PAS-136
Saginaw MI 48602
989-497-2500 x13101
Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens