Comfort Care...

Hi all,
I have a question about what is appropriate to code/query for in a patient on Comfort Care.

We have a 97yo who came in from the nursing home severely bradycardiac. She was being paced on arrival. In the ED they spoke to the POA who said that she did not want any pacing and removed the pads. Then she dipped into the 30's-40's. She was on 15L via face mask but later moved to RA and help sats at 90%. Palliative care was consulted and she was made comfort care. They did basic labs and a chest x-ray in the ED. We have cardiogenic shock, possible stroke, elevated troponin (they never state MI, but the EKG shows lateral infarct), and CKD 4 documented.

Since she was made CC in the ED, would it be appropriate to ask about a potential MI? We didn't do anything for her....


As a side note- she was made IP status but there are notes from UR stating that she didn't meet criteria. I am sure this will be denied.

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

Comments

  • edited April 2016
    I will be out of the office August 18 through August 24. If you need immediate assistance please contact me on my cell phone.


    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




Sign In or Register to comment.