coding question
OK, is it just because it is Friday afternoon and my brain is fried????
I sent this to our "coding judge" this morning. I had taken a case to dehydration w/pneumonia as the mcc. Coder took it to pneumonia w/o cc/mcc. There is good clinical support and documentation for '... 2 or more conditions on admission...'
Here is the answer I received:
Even though both pneumonia and dehydration were present on admission, the underlying cause of the dehydration was probably the pneumonia and therefore causing the admission. Dehydration is usually the outcome of an acute condition. We would want to pick up that acute condition rather than the dehydration. Eg. In our coding guidelines it is stated that if a patient is admitted with dehydration from acute renal failure, we must code the ARF 1st. On the opposite, if a pt is admitted with dehydration from gastroenteritis, the dehydration should be principal because of the focus of treatment...iv fluids treating dehydration.
What am I missing... this does not compute in my brain.
Thanks so much - always appreciate the opportunity to get new opinions.
Linnea Thennes, RN, BS, CCDS
Clinical Documentation Specialist
Centegra Hospital - McHenry
815.759-8193
lthennes@centegra.com
________________________________
This transmission may contain information that is privileged, confidential, or exempt from disclosure under applicable law. If you are not the intended recipient, consider yourself notified that any disclosure, copying, distribution, use, or reliance on this transmission is STRICTLY PROHIBITED. Please destroy this transmission in any format and notify the sender, if you received this transmission in error. Thank you.
I sent this to our "coding judge" this morning. I had taken a case to dehydration w/pneumonia as the mcc. Coder took it to pneumonia w/o cc/mcc. There is good clinical support and documentation for '... 2 or more conditions on admission...'
Here is the answer I received:
Even though both pneumonia and dehydration were present on admission, the underlying cause of the dehydration was probably the pneumonia and therefore causing the admission. Dehydration is usually the outcome of an acute condition. We would want to pick up that acute condition rather than the dehydration. Eg. In our coding guidelines it is stated that if a patient is admitted with dehydration from acute renal failure, we must code the ARF 1st. On the opposite, if a pt is admitted with dehydration from gastroenteritis, the dehydration should be principal because of the focus of treatment...iv fluids treating dehydration.
What am I missing... this does not compute in my brain.
Thanks so much - always appreciate the opportunity to get new opinions.
Linnea Thennes, RN, BS, CCDS
Clinical Documentation Specialist
Centegra Hospital - McHenry
815.759-8193
lthennes@centegra.com
________________________________
This transmission may contain information that is privileged, confidential, or exempt from disclosure under applicable law. If you are not the intended recipient, consider yourself notified that any disclosure, copying, distribution, use, or reliance on this transmission is STRICTLY PROHIBITED. Please destroy this transmission in any format and notify the sender, if you received this transmission in error. Thank you.
Comments
Thanks so much in advance,
Angela Susott CCS, CCDS