question
Happy Friday! Quick question! I have a chart where the ED provider says "SEPSIS, Pneumonia". The H&P says "sepsis due to pneumonia" (NO possible, probably, likely, or suspected, it says SEPSIS)... the Provider comes in and for a few days doesn't mention the sepsis again in his Progress notes, so for quality, I queried and it was responded to as "SEPSIS resolved but was present on admission". The very next day, the patient was discharged, and the Resident/faculty didn't put it on their dc summary. The coder wants me to query to get it added to the DC summary. (YES, they had + clinical indicators, tachypnea, tachycardia, < WBC, LA 1.89. + sepsis screen in ED")
I emailed our consultant (Claro) who agrees with me, that yes, in a perfect world, it would be nice to have on the DC summary, but since we don't code JUST OFF the dc summary that my current documentation supports the diagnosis. I would think since especially since I queried the day prior to DC and he confirms it is "resolved but was present on admission".
What do you think? DO your coders require all diagnosis' to be on the dc summary? Does anyone know if there is a coding clinic, advice about this. I swear I saw something once that says it doesn't have to be on the dc summary unless there was a possibility, suspicion of it-then it needs to be cleared up on the dc summary. This, however was a confirmed and documented diagnosis!
TIA!
Juli
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I emailed our consultant (Claro) who agrees with me, that yes, in a perfect world, it would be nice to have on the DC summary, but since we don't code JUST OFF the dc summary that my current documentation supports the diagnosis. I would think since especially since I queried the day prior to DC and he confirms it is "resolved but was present on admission".
What do you think? DO your coders require all diagnosis' to be on the dc summary? Does anyone know if there is a coding clinic, advice about this. I swear I saw something once that says it doesn't have to be on the dc summary unless there was a possibility, suspicion of it-then it needs to be cleared up on the dc summary. This, however was a confirmed and documented diagnosis!
TIA!
Juli
----------------------------------------------------------------------
Regional Health is an integrated health care system with the purpose of helping patients and communities live well.
Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
Comments
Pt with hx colon cancer and underwent chemo and had ileostomy placed. Eventually he had a "takedown" and is now coming back for an ELECTIVE colostomy due to < rectal tone and incontinence. He does NOT have excoriation, rectal ulcers, breakdown....nothing going on for wound etc. ..just says he cannot control his incontinence. (Not sure how long he had the ileostomy prior to the takedown)
So question? What would the PDX be? Considering it is elective and not due to breakdown, should she query for some sort of complication related to the cancer or Chemo? He is basically now incontintent....so wants the colostomy back...
TIA!
JUli