unexpected code/death
Hi everyone, I have a couple questions on a mortality record I am currently reviewing. This was an elderly woman who underwent an elective Total Knee. The procedure went fine without any identified issues. However, the day after the procedure the patient was found unresponsive. No pulse, no resp. Code was called. Epi was given, went into v-fib, delivered 3 shocks and amiodarone was given. Eventually we went into sincus with SBP in the 150's. then back to asystole, epi, CPR. Went back and forth several times. Patient also got bicarb and Ca in the process. BP was immeasurable in the later part of the code and dapoamine and levo were given. The code was an hour long until the husband requested we stop. The provider notes in the code note that 'the most likely diagnosis is a massive PE or massive heart attack"
Currently the only POA(N) dx the coder has is 'cardiac arrest'.
My questions are whether you would code the V-fib? Also, would you code the suspected PE and heart attack?
Would a query for shock be appropriate?
Thanks!
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
Currently the only POA(N) dx the coder has is 'cardiac arrest'.
My questions are whether you would code the V-fib? Also, would you code the suspected PE and heart attack?
Would a query for shock be appropriate?
Thanks!
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
Hi .. I would code the arrhythmia, arrest, manual ventilation/manual bagging, shocks delivered & or intubation w/ manual ventilation, along with lines and any infusions inserted or started.
However, I would only would code the suspected condition/ cause of death if pulled into the discharge summary and would capture both if the physician stated "or" between the conditions.
No, I would not query for shock as she is already past that stage when arrest was identified. I would check vitals for signs & any signs of something brewing prior to the arrest. Checking for signs hypoxia, or hypotension, respiratory distress, prior to the arrest- along with any abnormal lab work that would impact this post op patient- HG, glucose, EBL in surgery, VS during surgery, k+, renal function, I&O, acidosis etc...
Have a great weekend! Laurie
S
Thanks!
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
Sent from Yahoo Mail for iPhone
On Friday, January 22, 2016, 3:54 PM, CDI Talk wrote:
Great discussion. Guidelines for determining cause of death for the purposes of medical records keeping are provided by the UHDDS guidelines and are described pretty nicely here: http://www.cdc.gov/nchs/nvss/death_certification_problems.htm
I think this will make you feel pretty secure on how to code the event.
Dr. G.