A question

Snook@fmchealth.orgSnook@fmchealth.org
edited May 2016 in CDI Talk Archive
I need some advice. Does one always put the highest weighted diagnosis that is POA? I have a patient with acute pancreatitis with acute renal failure. Many times the ARF is the highest weight but it is not the focus of the admission. What it the consensus?

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



--
Fairfield Medical Center
People you know. Care you trust.


Comments

  • heidi.koenigheidi.koenig
    edited May 2016
    I do not. The coders generally will, but that can come back to bite you. We had a case where the patient was a trauma. They had a fractured toe and femur. The coder put the toe as PDX and femur as SDX (MCC). We sent it back, because the fractured femur more accurately reflected the care given, but had lower weight. And one case like that that RAC finds.....This is a primary point of contention with our staff.


  • ssalinasssalinas
    edited May 2016
    Are we talking about principal diagnoses and DRGs? If so, the weight of the DRG should have nothing to do with the selection of the principal diagnosis UNLESS

    * you have 2 conditions that equally meet the definition of Pr Dx

    * 2 inter-related conditions that equally meet the definition of PR DX.


    The principal diagnosis is "that condition established after study for occasioning the admission of the patient to the hospital for care." The diagnostic workup and/or therapy provided all enter into making this determination.



    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





  • gwojogwojo
    edited March 2016
    Hi Mary, I do not always go with the highest weighted DRG unless I have back up to support my decision. I always code so I can intelligently defend my pdx; and that includes the focus of the admission.
     
    I review IV drugs, test performed, specialist involved, etc. If a patient comes in with an infected ulcer along with acute CHF and IV abx is directed to the ulcer the entire stay and one time IV Lasix for the CHF I would go with the ulcer as pdx.
     
    There are alot of variables that factor into a pdx, more than just being poa. Do you feel comfortable discussing with your coder why he/she is changing the pdx?

Sign In or Register to comment.