Medications without indication

arsusott@msn.comarsusott@msn.com
in CDI Talk Archive
Can anyone direct me to a coding guideline or other guideline regarding medications given without indication. I am trying to find something that supports the need for a query to be placed if a pt is receiving the same meds as at home but doesn't have a dx to support the meds. We are revising our Med Reconciliation Sheet which has a spot for indication but it is routinely not filled out completely as far as the indication for the meds, which if the med is given in the hospital I feel I have a case for a query since it was therapeutically treated. I liked 3Q 2005 Coding Clinic regarding Coding and Physician Orders. But is there anything else out there that shows that each med given should have a diagnosis linked to it?

Thanks so much,
Angela Susott

Comments

  • Unknown
    edited May 2016
    Yes, if the physician doesn't list the diagnosis with the med, he is shortchanging his medical decision making, misrepresenting the complexity of the case and potentially under representing his/her E & M .



  • robert.hodges2robert.hodges2
    Check AHIMA's Managing an Effective Query Process. The 5th bullet from the piece I inserted below should cover this question :)

    Documentation and Coding
    As a result of the disparity in documentation practices by providers, querying has become a common
    communication and educational method to advocate proper documentation practices. Queries may be made in
    situations such as the following:
  • kmaritankmaritan
    edited May 2016
    I have written clarifications for secondary diagnoses for various meds ordered at admission.


  • arsusott@msn.comarsusott@msn.com
    Thank you... We the CDI Team normally do query for meds given without a dx and they normally respond. We are just trying to find a coding rule or guideline that states every drug given must have a dx attached to it to show to our QRM department who is in the process of updating a form. They had mentioned that it is not a compliance issue (which I agree it is not a nursing compliance issue) it is just an issue of not having a dx attached to the meds. We felt that if on the form there was a spot for a dx and the physician signed off on it then we could code from those forms. So just looking for any resources to show them.

    I love CDI Talk, thanks for the responses.
  • judithbatesjudithbates
    edited May 2016
    I think this speaks to the guidelines that anything that is treated (that would be continuing home meds), evaluated or monitored...Needs a corresponding diagnosis...Not sure that you would find a coding rule per se that you can attach to the situation...

    Judi Bates RN, BSN, CCDS
    CDI Specialist
    856-757-3161
    Beeper 66x2906

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