Please help
Patient is a 70-year-old Caucasian female with a past medical history significant for hypertension, diabetes, morbid obesity, Chronic obstructive pulmonary disease, tobacco abuse, pulmonary embolism and DVT on chronic Coumadin therapy. Patient presented today to the emergency room via ambulance with complaints of altered mental status. According to the daughter, who is at the bedside the patient was completely unresponsive earlier today at home. She had been eating, and when the daughter checked on her, she was completely altered unresponsive and frothing from the side of her mouth. There is no evidence that the patient had a seizure, however she does have some myoclonic jerks especially in the left upper extremity. No history of for bowel or bladder incontinence. Patient was therefore brought into the emergency room for evaluation and management. In emergency room, she had a CT scan of the head that was unremarkable. She however had a chest x-ray that showed minimal left basilar pneumonia for which she was started on Levaquin 750 mg IV x1. The patient is a poor historian, so most of this history was obtained from the daughter and ER documentation. She actually fell 2 days ago and sustained bruising and hematoma of the right lower extremity. According to her, she was walking towards the house when she fell. She was brought into the emergency room and was treated and sent back home. The pain persisted today and is not clear whether she may have taken more for her hydrocodone then prescribed. Per the daughter, she reports that she has been given the patient her medications. Her urine tox screen was positive for opioids. Her labs reviewed, pertinent for hypomagnesemia with magnesium 1.7, a white count of 11.3. She also had a blood gas which showed pH of 7.43 with a PO2 of 61 and a pCO2 53. She does have a history of emphysema and Chronic obstructive pulmonary disease. Patient has therefore been admitted to the service of Dr Mohamed Dauda for further medical management.
Pneumonia was principal diagnosis coded
During the hospital stay the patient had a hematoma (sustained from fall 2 days prior to admit) that was drained by the surgeon and the patient also had separate procedure for excision of necrotic tissue after that.
MCR sent denial stating the primary diagnosis does not support the procedure.
PLEASE ADVISE.
Thanks tremendously!
Pneumonia was principal diagnosis coded
During the hospital stay the patient had a hematoma (sustained from fall 2 days prior to admit) that was drained by the surgeon and the patient also had separate procedure for excision of necrotic tissue after that.
MCR sent denial stating the primary diagnosis does not support the procedure.
PLEASE ADVISE.
Thanks tremendously!
Comments
Please share the outcome if/when you learn what to do.
Vanessa Falkoff RN
Clinical Documentation Improvement Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
Compassion * Accountability * Respect * Integrity
Sent from my iPhone
Deanna Holowczak, RN, MSN, CCDS
Clinical Documentation Specialist
St. John's Riverside Hospital
dholowczak@riversidehealth.org
(914) 964-4580
Cell (914)560-6673
Part of original message pertinent for PNA is as follows: "She however had a chest x-ray that showed minimal left basilar pneumonia for which she was started on Levaquin 750 mg IV x1. a white count of 11.3. She also had a blood gas which showed pH of 7.43 with a PO2 of 61 and a pCO2 53. She does have a history of emphysema and Chronic obstructive pulmonary disease. Patient has therefore been admitted to the service of Dr Mohamed Dauda for further medical management"
Your message does not indicate any further w/u or therapy towards suspected or known Pneumonia - did the patient continue to receive treatment for a PNA that would not typically be provided in a non-acute setting, and more aggressive therapy towards some other condition?
Did she have a fever? Did further radiological studies support a diagnosis of pna? Per documentation you can cite, she was admitted to Dr. XX for further medical mgt of ???
Many pts have a pneumonia which may not require acute admission....the documentation cited does not necessarily indicate or support any particular condition as a principal diagnosis.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Under any circumstance, the pneumonia must meet the definition of the principal diagnosis....
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The PNA should also meet medical necessity for admission condition.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
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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Section II. Selection of Principal Diagnosis
The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."
The UHDDS definitions are used by hospitals to report inpatient data elements in a standardized manner. These data elements and their definitions can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp. 31038-40.
Since that time the application of the UHDDS definitions has been expanded to include all non-outpatient settings (acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc).
In determining principal diagnosis, coding conventions in the ICD-10-CM, the Tabular List and Alphabetic Index take precedence over these official coding guidelines.
(See Section I.A., Conventions for the ICD-10-CM)
The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation the application of all coding guidelines is a difficult, if not impossible, task.
A. Codes for symptoms, signs, and ill-defined conditions
Codes for symptoms, signs, and ill-defined conditions from Chapter 18 are not to be used as principal diagnosis when a related definitive diagnosis has been established.
B. Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis.
When there are two or more interrelated conditions (such as diseases in the same ICD-10-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Page 97 of 115
C. Two or more diagnoses that equally meet the definition for principal diagnosis In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first. D. Two or more comparative or contrasting conditions In those rare instances when two or more contrasting or comparative diagnoses are documented as "either/or" (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first. E. A symptom(s) followed by contrasting/comparative diagnoses GUIDELINE HAS BEEN DELETED EFFECTIVE OCTOBER 1, 2014 F. Original treatment plan not carried out Sequence as the principal diagnosis the condition, which after study occasioned the admission to the hospital, even though treatment may not have been carried out due to unforeseen circumstances. G. Complications of surgery and other medical care When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the T80-T88 series and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned. H. Uncertain Diagnosis If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
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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I hope you are doing well. Did the denial letter suggest what the PDX should be or just state it wasn't related?
David Reece, BSN, RN, CCDS
Manager, Quality Documentation Services
Premier, Inc.
Cell: 336-480-7541
David_Reece@PremierInc.com
So glad you saw the red flag and responded, bout to throw up white flag!
Thanks,
Kim
David Reece, BSN, RN, CCDS
Manager, Quality Documentation Services
Premier, Inc.
Office: 704-816-4462
Cell: 336-480-7541
David_Reece@PremierInc.com