query for Alcohol/Drug use/abuse/dependence

ehicoxehicox
edited March 2016 in Clinical & Coding
In MS DRGs if the physician links alcohol use, abuse or dependence to anxiety, it will yeild a CC. When I mentioned this to a friend who is a coder, she felt it would not be appropriate to query for this link based on the patient's documented alcohol abuse,anxiety and home medication of xanax, continued in the hospital. I have looked for some article or guidence on when to query for clarification of these situations, and have not found much.
Does anyone have a guideline re: what clinical indicators would need to be present to query for a link between behaviors/psychosis and alcohol/substance abuse/dependence?

Thanks,
Elizabeth Hicox, RN, BSN, CCDS,CCS
ehicox@thinkbrg.com

Comments

  • utuk350@hotmail.comutuk350@hotmail.com
    edited March 2016
    Hello,

    Querying the physician to link the two diagnoses without any evidence of association introduces a new information into the medical record.

    It would be appropriate to query the physician to document the etiology of anxiety if known. If the physician documents anxiety due to etoh use, then you would have the link without introducing new information into the medical record.

    Margaret Utuk, RN, MJ, CCDS

    On Feb 10, 2016, at 5:52 PM, CDI Talk wrote:

    In MS DRGs if the physician links alcohol use, abuse or dependence to anxiety, it will yeild a CC. When I mentioned this to a friend who is a coder, she felt it would not be appropriate to query for this link based on the patient's documented alcohol abuse,anxiety and home medication of xanax, continued in the hospital. I have looked for some article or guidence on when to query for clarification of these situations, and have not found much.
    Does anyone have a guideline re: what clinical indicators would need to be present to query for a link between behaviors/psychosis and alcohol/substance abuse/dependence?

    Thanks,
    Elizabeth Hicox, RN, BSN, CCDS,CCS
    ehicox@thinkbrg.com
  • ehicoxehicox
    edited March 2016
    Thanks Margaret, your response has helped me sort out the process. The query is really for the etiology or relationship, if any, between the substance abuse/dependence and documented conditions with continued treatment during the hospital stay.
    Thanks again,

    Elizabeth
  • utuk350@hotmail.comutuk350@hotmail.com
    edited March 2016
    Hello Elizabeth,

    You are welcome!

    On Feb 11, 2016, at 9:18 AM, CDI Talk wrote:

    Thanks Margaret, your response has helped me sort out the process. The query is really for the etiology or relationship, if any, between the substance abuse/dependence and documented conditions with continued treatment during the hospital stay.
    Thanks again,

    Elizabeth
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