Conditions resolving in the ER

katysuegood@gmail.com

It is my understanding that conditions that were present in the ER but resolved prior to IP admission should be coded on the IP encounter. Do you require that the attending confirm that these Dx were present? This is different than a differential dx that requires continued workup and confirmation by the attending. I am specifically referring to a condition that was present in the ED, treated, and resolved prior to IP admission.

Also, any references would be appreciated.

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

mary.valentino.rn

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I have the same understanding as you, that it would be coded on the IP
encounter. I also checked with the coders - and they agreed. The attending
would need to confirm - assuring it is written in the discharge summary as
well. We recently had some denials from medicare, that even though
documentation was in progress notes, since not included in the discharge
summary, monies for that diagnosis were denied.
Just something else to look out for.

Mary Jean Valentino, RN CDS

Mary Jean Valentino
(302) 299-6327

evanspx@sutterhealth.org

Coded w/ IP Encounter if not contraindicated. Does not require confirmation from Attending nor inclusion in Summary. However, as we know, many 3rd parties insist upon these conditions. However, C. Clinic clearly states ED diagnosis, clearly documented and supported, are coded. In this era whereby many payers seem to be enforcing arbitrary rules, I understand why there is much confusion.

Reference That is Pertinent:


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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

Unknown

A little care, here. Sometimes the think that brought the patient to the ED might resolve but it was not the condition that led to the decision to admit. That should not be coded on the inpatient encounter if it resolves. It’s those diagnoses that, at the time decision was made to admit the patient, participated in that decision - these get coded on the inpatient encounter. If a patient appeared with a splinter and it was removed and, while in the ED, someone noticed that the patient was pale and hemoglobin was obtained and found to be 5.6 and a black stool hemoccult was strongly positive, the patient was admitted for upper GI bleed and anemia presumably due to the bleed (but we don’t know if it’s acute or chronic - but we DO!) The splinter was not there anymore and didn’t participate in the decision to require inpatient care.

Robert S. Gold, MD
CEO, DCBA, Inc
4611 Brierwood Place
Atlanta, GA 30360
(770) 216-9691 (Office)
(404) 580-0204 (Cell)

evanspx@sutterhealth.org

The encounter begins in the ED and the diagnoses and conditions treated in the ED are combined w/ the IP admission. If the ED staff successfully reverse or begin to treat acidosis, respiratory failure, or shock, these should be included on the billing for the inpatient encounter.




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

katysuegood@gmail.com

Thanks Paul! That’s exactly what I was looking for and I just couldn’t find it for some reason.

F

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

evanspx@sutterhealth.org

The procedures performed by an ED MD for a pt subsequently admitted are coded to the inpatient encounter. A few examples would be excisional debridement, suture of skin, fascia, muscle, intubation, and initiation of mechanical ventilation. For the inpatient facility, all diagnoses treated and procedures performed in the ED encounter resulting in submission of an inpatient claim are reported on one claim…there is not a separate claim for the ED visit with a separate claim for the acute, inpatient visit.

Example: Pt is admitted via ED with ARF 2/2 Rhabdomyolysis – patient was found down on hard surface for extended period of time as she fell. The fall resulted in significant trauma (tear) of muscle in her skull – the ED MD documents a repair of complex wound with suture repair of tendon/muscle. This will be reported on the inpatient claim, and is an procedure that can impact MS-DRG Assignment.

It does not often very often, but there are select procedures performed by the ED MD that impact DRG. I am citing this as a response as these are not theoretical scenarios, but situations I have personally reviewed and coded.



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

Snook@fmchealth.org

There is a question in the CCDS exam book on the practice test that relates to this very situation. Patient arrives with Acute Respiratory Failure and Pneumonia. The respiratory failure was resolved in the ED. Patient was admitted and the question was what is the PDx? My guess of respiratory failure was incorrect. It was the pneumonia. I am only in my third year of CDI. What is your opinion? My exam is coming soon!

Mary L. Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
740-689-4443
snook@fmchealth.org

katysuegood@gmail.com

The pneumonia would be Pdx because it’s what caused the admission and was the focus of care. ARF had resolved at IP admission so it would not be PDX. But the ARF should be coded as a Sdx because all conditions present/evaluated/treated should be coded in the IP encounter.

Good luck on your exam!

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

Snook@fmchealth.org

Thank you for your help Katie!

Mary L. Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
740-689-4443

nameher

paul_evans_90314 said:

The encounter begins in the ED and the diagnoses and conditions treated in the ED are combined w/ the IP admission. If the ED staff successfully reverse or begin to treat acidosis, respiratory failure, or shock, these should be included on the billing for the inpatient encounter. 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

Paul, can we take this one step further.  A patient is seen in the ED at a tertiary facility for septic shock secondary to postop infection of a recent joint replacement.  Pt is transferred from the ED to another hospital for admission.  The patient's blood pressure has normalized, and he is being tx with antibx, planned surgery and holding antihypertensives.  Would you code septic shock?

sbrodie@hcpro.com

it is a little different when you are talking about a patient being transferred to another facility. they would have been discharged from one facility and admitted to another?

evanspx@sutterhealth.org

The issue of coding via ED is a common theme and can't be fully covered via a forum.  A few general points. 

Can we code directly from an ED note :  My response-  Consider the ED note to have the same impact as any other note, and if the condition is clearly stated with clinical support, it may be coded.  If the condition seems to lack clinical support - it would need to be 'validated'.  (see ACDIS Paper on Validation)

Coding Clinic provides an oft-cited scenario in which 'only' the ED MD stated 'acute respiratory failure'.  The condition is strongly supported with traditional criteria, and Coding Clinic states one should code the condition as long as there is no further charted dissonance or reason to question the diagnosis.

I think it is important to remember that the ED physician will enter many possible or potential conditions that may need to be investigated - with some potentially ruled out after study.  The ED MD may record 'MI' or Sepsis as a working condition, and either may be ruled out or confirmed after admission.

For the scenario at hand, if there are not current clinical indicators supporting the patient is experiencing septic shock, I'd think a validation would be in order.

Paul Evans

CCDS