Coding inpatient visit- what is point of entry to count?
I may have poor recall, but thought that when I took the ACDIS boot camp, we were taught to look at the point of entry- ambulance run sheets, ED records from stabilizing facility ( lower level of care and transfer to higher level)... If a patient was taken by ambulance to nearest facility and has sob/chf... was give Lasix Iv or put on bipap and transferred to a another facility. the acute chf and respiratory failure could be captured or queried as those are really the acute conditions that necessitated a higher level of care... Currently I am hearing that anything that occurs in the other ED, is not coded as part of this admission... thoughts? Nuances of when it would or would not?
Thanks!
Comments
If we receive transfers from other facilities, our practice is to clarify for conditions that appear on our facility's transport records during the transport because that is considered the point of entry in which our physicians become involved in the care of the patient. We use vitals, gases, etc from the transport documentation and not from EMS runs to ED or ED notes from the referring facility.
Jackie Touch