What is the code for Pancytopenia due to Substance Abuse?
Pancytopenia likely secondary to substance abuse documented in the discharge summary.
Progress note- Pancytopenia secondary to loss of proteins-monitor counts for now, no indication for transfusion, no active bleed
Coded to D61.811 by the coder (other drug induced pancytopenia-MCC).
Is this the correct code, as per the physician's documentation?
Code increases SOI/ROM from 2/1 to 3/2.
Please see the details below.
Discharge Summary Final Diagnoses:
Nephrotic syndrome, unclear etiology s/p biopsy
AKI secondary to nephrotic syndrome
Continuos substance abuse snorting of heroin (heroin abuse, IVDA also documented in the medical record, on Suboxone)
Nicotine dependence
Pancytopenia likely secondary to substance abuse
Suspect MGUS (patient refused oncology workup)
Mayra Luciano, BS, BSN, RN
Clinical Documentation Improvement Specialist
Brookhaven Memorial Hospital Medical Center
101 Hospital Road
Patchogue, NY 11772
631 438 5268
mluciano@bmhmc.org
Progress note- Pancytopenia secondary to loss of proteins-monitor counts for now, no indication for transfusion, no active bleed
Coded to D61.811 by the coder (other drug induced pancytopenia-MCC).
Is this the correct code, as per the physician's documentation?
Code increases SOI/ROM from 2/1 to 3/2.
Please see the details below.
Discharge Summary Final Diagnoses:
Nephrotic syndrome, unclear etiology s/p biopsy
AKI secondary to nephrotic syndrome
Continuos substance abuse snorting of heroin (heroin abuse, IVDA also documented in the medical record, on Suboxone)
Nicotine dependence
Pancytopenia likely secondary to substance abuse
Suspect MGUS (patient refused oncology workup)
Mayra Luciano, BS, BSN, RN
Clinical Documentation Improvement Specialist
Brookhaven Memorial Hospital Medical Center
101 Hospital Road
Patchogue, NY 11772
631 438 5268
mluciano@bmhmc.org
Comments
This was very helpful.
See you in Atlanta!
Mayra Luciano, BS, BSN, RN
Clinical Documentation Improvement Specialist
Brookhaven Memorial Hospital Medical Center
101 Hospital Road
Patchogue, NY 11772
631 438 5268
mluciano@bmhmc.org