PCS is KILLING me!!

katysuegood@gmail.comkatysuegood@gmail.com
in Clinical & Coding
Whew!

Trauma undergoes an closed reduction and external fixation procedure. Coding told me they did not have enough information to code the procedure. They want queries for the approach, device specificity, location...

This is what I see:

[cid:image002.png@01D16A57.0ACAD8E0]


Then from post-op xray....

[cid:image004.png@01D16A4F.33DAC130]


I go here:

[cid:image003.png@01D16A4F.33DAC130]

Without a query.


But do we need to code the placement of the fixation decide separately? And if so, do you think the approach is clear or are queries needed?


We are getting quite a few requests for queries on PCS stuff that is actually in there its just not in 'coding language'. I am trying to be diligent about making sure queries are needed. But it is time consuming and PCS is definitely NOT my forte ;-)

Thanks!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

Comments

  • cheree.lueck@dhha.orgcheree.lueck@dhha.org
    Katy,
    The ex fix device is not coded separately, as it is included in the closed reduction. You account for it in the device character. The report stated "the external fixator was tightened down...", so I'm not sure a query is required for the device, as it seems fairly clear what device was used to keep the fracture reduced.

    Also, the fracture is open, but they do not state that they made a separate or deepened the incision to reduce the fracture. They clearly have stated that they performed a closed reduction (external approach) of the fracture & then irrigated the wound or "open part" and eventually go on to close and dress this wound.

    The body part seems fairly clear as well in the axial images as to where the pins of the exfix are placed. I would code this out the same way that you did if I were looking at this. I personally, would not send a query out on this case, as it seems very clear what they did.

    I'm curious as to what "coding language" they would like the surgeon to use. (externally reposition? , exfix device?, L ankle joint???)

    Those are my thoughts.
    Cheree


    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Thursday, February 18, 2016 2:22 PM
    To: Lueck, Cheree RN
    Subject: [cdi_talk] PCS is KILLING me!!

    Whew!

    Trauma undergoes an closed reduction and external fixation procedure. Coding told me they did not have enough information to code the procedure. They want queries for the approach, device specificity, location...

    This is what I see:

    [cid:image002.png@01D16A5A.F4B923F0]


    Then from post-op xray....

    [cid:image004.png@01D16A5A.F4B923F0]


    I go here:

    [cid:image005.png@01D16A5A.F4B923F0]

    Without a query.


    But do we need to code the placement of the fixation decide separately? And if so, do you think the approach is clear or are queries needed?


    We are getting quite a few requests for queries on PCS stuff that is actually in there its just not in 'coding language'. I am trying to be diligent about making sure queries are needed. But it is time consuming and PCS is definitely NOT my forte ;-)

    Thanks!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404




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  • ssalinasssalinas
    edited March 2016
    Are the coders looking at this as an ankle fracture or as fracture of fib, tib and talus? Based on what they asked for, I think it might be the latter since additional info would be required for the external fixation device in that scenario. If the diagnosis was clarified with them, the request for queries might go away. Just a thought...
    [cid:image004.png@01D16A6D.C597E260]

    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

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Thursday, February 18, 2016 1:22 PM
    To: Salinas, Sharon
    Subject: [cdi_talk] PCS is KILLING me!!

    Whew!

    Trauma undergoes an closed reduction and external fixation procedure. Coding told me they did not have enough information to code the procedure. They want queries for the approach, device specificity, location...

    This is what I see:

    [cid:image005.png@01D16A6D.C597E260]


    Then from post-op xray....

    [cid:image004.png@01D16A4F.33DAC130]


    I go here:

    [cid:image003.png@01D16A4F.33DAC130]

    Without a query.


    But do we need to code the placement of the fixation decide separately? And if so, do you think the approach is clear or are queries needed?


    We are getting quite a few requests for queries on PCS stuff that is actually in there its just not in 'coding language'. I am trying to be diligent about making sure queries are needed. But it is time consuming and PCS is definitely NOT my forte ;-)

    Thanks!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404




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