transfusions

deanne_wilkdeanne_wilk
in CDI Talk Archive
Is everyone coding transfusions?


Deanne Wilk, BSN, RN, CCDS, CCS
AHIMA approved ICD-10-CM/PCS Trainer

Clinical Documentation Improvement and Inpatient Coding Manager
HIMS Department
Good Samaritan Health System
4th & Walnut Sts
Lebanon, PA 17042
dwilk@gshleb.org

Phone: 717-270-7582
Cell: 717-580-1436




This Message is intended only for the use of the individual or entity to which it is addressed, and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination or copying of this message or the taking of any action in reliance on the contents of this message is strictly prohibited. If you have received this message in error, please notify us immediately and destroy the original message. Thank you.

Comments

  • martin.conroymartin.conroy
    edited April 2016
    With ICD-10 who would have the time to code ancillary PC.

    Marty

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    Routine and high-volume procedures, such as transfusions, that do not impact grouper assignment are not coded individually. For research and tracking, these types of procedures can be tracked via the Charge Description Master in a hospital.



    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421

    evanspx@sutterhealth.org

  • deanne_wilkdeanne_wilk
    edited April 2016
    So you are not coding even when there is a transfusion reaction?


    Deanne Wilk, BSN, RN, CCDS, CCS
    AHIMA approved ICD-10-CM/PCS Trainer

    Clinical Documentation Improvement and Inpatient Coding Manager
    HIMS Department
    Good Samaritan Health System
    4th & Walnut Sts
    Lebanon, PA 17042
    dwilk@gshleb.org

    Phone: 717-270-7582
    Cell: 717-580-1436



  • cynthia.hudson@christushealth.orgcynthia.hudson@christushealth.org
    edited April 2016
    We code whatever is documented. If there is a reaction, we code it.

    Syndi Hudson, RN, CCDS,CCM
    CHRISTUS Santa Rosa New Braunfels
    CDI Specialist
    cynthia.hudson@christushealth.org
    830-643-6116 (Office)
    830-643-5139 (Fax)
    [Description: CCDS_pin_1inch]
    "We are His hands". Isaiah 64:8

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    No...code the reaction, but there is no need to code transfusions....think of the volume! One has to abstract and note every date and every unit by type...FFP, PRCS, et al. For trauma cases, the volume of coding would be prohibitive.

    Coders do not 'hard code' chest films, transfusions, and other ancillary services.

    Paul

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421

    evanspx@sutterhealth.org

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    Yes...but there is no need to code the transfusion PROCEDURE....

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421

    evanspx@sutterhealth.org

  • cynthia.hudson@christushealth.orgcynthia.hudson@christushealth.org
    edited April 2016
    I agree. We don't code that. I am sorry if I misunderstood.

    Syndi Hudson, RN, CCDS,CCM
    CHRISTUS Santa Rosa New Braunfels
    CDI Specialist
    cynthia.hudson@christushealth.org
    830-643-6116 (Office)
    830-643-5139 (Fax)
    [Description: CCDS_pin_1inch]
    "We are His hands". Isaiah 64:8

  • ssalinasssalinas
    edited April 2016
    Currently coders code it once for each type of transfusion which is the same way we code dialysis. This helps with data retrieval using ICD-9-CM codes. I believe our policy will change with I-10.

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    Vary by site. Never asked my coders to code since codes should be found in cdm. Imo not good use of coder time, but see some may wish to code,

  • ssalinasssalinas
    edited April 2016
    It takes about 5 seconds per code to code and abstract for a maximum of 25 seconds. Info very easy to find in EHR. Saves a lot of time running reports since we are able to pull just from abstracting instead of having to pull from CDM database. With our software, this is a big plus!

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    Understood, but do you code each, every and all transfusions? If not, and a site only codes the 'first' transfusion, it seems the data is not accurate. Some trauma patients receive many and repeated blood products. However, I understand how/why some sites may make a choice to code this ancillary service. But, I don't think a person performing CDI work should code such services.

    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.412.9421

  • deanne_wilkdeanne_wilk
    edited April 2016
    Yeah I am getting mixed information online as well. CMS discusses transfusion coding as does HcPro. I have always coded transfusions but current facility does not. I am trying to find something definitive. My issue is that if there is a reaction from a transfusion I think the actual procedure should be reflected in the coding as well.


    Deanne Wilk, BSN, RN, CCDS, CCS
    AHIMA approved ICD-10-CM/PCS Trainer

    Clinical Documentation Improvement and Inpatient Coding Manager
    HIMS Department
    Good Samaritan Health System
    4th & Walnut Sts
    Lebanon, PA 17042
    dwilk@gshleb.org

    Phone: 717-270-7582
    Cell: 717-580-1436



  • ssalinasssalinas
    edited April 2016
    It is coded once for each type of transfusion which is the same way we code dialysis. Agree with Paul that transfusion coding does not need to be done by CDIs.

    If we want to know volume, the BAR/CDM database is accessed. If we just want to identify a specific subset of patients, say those who had HD and blood transfusion, then we can more easily and quickly do that out of the abstracting/coding database. This is especially true if we throw a specific diagnosis into the mix.

    I do and have coded for many different hospitals and all had coding identify one occurrence of each. However I think with i-10, that may well change.

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org


Sign In or Register to comment.