PCS codes

cheree.lueck@dhha.orgcheree.lueck@dhha.org
in CDI Talk Archive
Hi all,
I'm curious as to how other facility's' coders and CDI are building their PCS codes. Are you using the entire record (H&P, progress notes, DC sum, etc.) to code the procedure, or are you using only the procedure report (dictated report) to build the PCS code(s)?

Thanks,
Cheree Lueck, RN, CDI





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Comments

  • mulled2mulled2
    edited March 2016
    Procedure/OP note

  • ssalinasssalinas
    edited March 2016
    I use documentation by the surgeon such as the handwritten post-op note, progress notes or ? that was done at the time of the procedure or after in addition to the dictated report. This is especially true as they get use to what is required in I-10 PCS. If there is a discrepancy, then a query may be necessary. If it is just more detailed info, I use it.

    I also use cath lab, IR data, implant record, etc. for info regarding type of stents, grafts, etc. if the surgeon does not provide the specific type.

    I don't use anything provided prior to surgery such as H&P or consults since plans change.

    Should I not be doing this???

    Others?

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited March 2016
    My practice is the same as that outlined by Sharon. The Cardiac Catheterization reports are very helpful in regards to devices used, as well as any Interventional Radiology Reports.

    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

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