in the setting of...

kerryseekircherkerryseekircher
edited May 2016 in Clinical & Coding
Our MD's go to term is 'in the setting of'. I really like it when they use it to include clinical indicators to help support/describe a diagnosis, but am on the fence when used as a link between a procedure and a complication.
Is a query still warranted for the following?
Severe Sepsis in the setting of a prostate biopsy 2 days prior.
Also documented post-op sepsis following prostate biopsy.

Is it still best to clarify if 'due to'?

Thanks!
Kerry

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Comments

  • dsmith12h@aol.comdsmith12h@aol.com
    edited May 2016
    We are told to query for for "due to" or "associated with with".

    Debbie Smith
    UTSW



  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Hi Kerry,

    I don’t think ‘in the setting of’ is enough to establish a cause/effect relationship. I would query for the complication in these scenarios. Although, I would note that many of the risk-adjusted methodologies/PSI’s/etc are likely capturing post-op sepsis (for ex) as a complication regardless of whether it was specified as one.

    ☺

    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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