complications due to anes

hillsandovals@email.chop.eduhillsandovals@email.chop.edu
in Pediatrics

Hi, CDI members. I have a question about what can or can't be coded. It was documented in a patients' chart , "  child was unable to tolerate feeds post anes." The coder coded this as feeding intolerance/difficulties.

I coded it as feeding intolerance due to post anes.

The coder stated that since it was never documented that it was a complication or due to anesthesia, it could not be documented as a complication of anesthesia.

Your thoughts?


Thanks in advance.


Steph

Comments

  • vparent@emhs.orgvparent@emhs.org

    Personally, I would not code it as a complication of anesthesia. I would assume this means the child was nauseous after surgery which is a frequent occurrence and not necessarily a complication. If it didn't mean nausea, a query would be needed to determine what "unable to tolerate feeds post anesthesia" actually means. The second question is, was it a GI surgery or some other type of surgery which effects the coding pathway.

    Valerie

  • hillsandovals@email.chop.eduhillsandovals@email.chop.edu

    Hi Valerie, this was a routine EGD.

    Thanks, Steph

  • jackietouch@aol.comjackietouch@aol.com
    Hi, Steph~

    I would not pick up as a complication as documented. Another thing to consider is if this was an outpatient procedure that was converted to inpatient status due to the inability to tolerate feeds. If so, you may need to query in order to accurately assign your PDx. 

    Jackie
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