Coding an observation diagnosis resolved prior to conversion to inpatient

jlightfoot@marshallmedical.orgjlightfoot@marshallmedical.org
in CDI Talk Archive
We had an observation patient who was admitted as an inpatient 3 days later; during the OBS period she had a toxic encephalopathy that was clearly resolved prior to conversion to inpatient. There is no documentation of encephalopathy after the status change. If coded, this will be our only MCC on an MS DRG case. Is this a valid diagnosis as it was technically not evaluated or treated during the "inpatient" admission? Thanks in advance for any guidance.

Jillian Lightfoot RN
Clinical Documentation Team
Marshall Medical Center
Placerville, CA 95667
(530) 626-2770 Ext. 6203
jlightfoot@marshallmedical.org

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Yes, anything that occurred during the OP status should be coded for the encounter. This is my understanding.

    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


  • jolene.filejolene.file
    edited April 2016
    I agree. The Observation stay is rolled into the INPT record for billing so the encephalopathy maybe coded on the IP record. The reason for IP admit should be the PDX.

    Jolene File,RHIT,CCS,CPC-H,CCDS
    Documentation Improvement Specialist-Coder
    Hays Medical Center
    jolene.file@haysmed.com

  • jlightfoot@marshallmedical.orgjlightfoot@marshallmedical.org
    Thank you for responding. Apparently I wasn't "logged in" and didn't know until this am that anyone had responded. I appreciate the input :)
Sign In or Register to comment.