to query or not??

I wanted to get some guidance/opinions on two questions we had come up with documentation around brand names versus generic/ types and if we should query or not. Our coding department is unsure which way to go or if a written policy would cover this and prevent the need to query. Thanks in advance for any feedback.

1. Is it necessary to query for the material type on a hip replacement when the provider documents the brand name of the device?

2. If the physician documents in his notes that he used Isovue or another specific name brand of contrast, do we need to query to see if it is high or low osmolarity?

David Reece, BSN, RN
Manager, Clinical Documentation Improvement
Clinical Improvement
Novant Health
office: 336-277-1935
fax: 336-277-8045
dreece@novanthealth.org

Comments

  • edited April 2016
    Hi!

    It is my opinion that you would not need to query for low osmolar or high osmolar as long as the type/brand of contrast is documented by the physican in the record. I would think that radiology would keep a listing of which contrasts are used at the facility and would be able to classify as low osmolar or high osmolar for you. The info should be shared with the coding staff so they can assign the correct type that was utilized.

    Likewise, surgery should be able to help you to classify the type of material in the hip replacement. Maybe they could prepare a list of what is used in surgery. Just as with the stents, it is not required for the cardiologist to say DES or NDES. If the brand/type is documented than the coder will code to the specific type as DES or NDES.

    I think it is much easier for the coder if the specificity is documented but I do not believe a requirement. I am not sure I would query. This would be a hospital decision.

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

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