coding diagnosis documented as expected

mulled2

What is the coding guidance on coding or not documentation that is written as expected. for example patient has

CABG. They document acute resp failure expected or CV shock expected. The patient is vented and is on drips.  Then they stay on the drips or don't get extubated. What it the CDI role in this. I don't believe you can just ignore the documented diagnosis even if its written as expected. please dvise

Thanks

vparent@emhs.org

IMO, no you cannot ignore, we recommend and have educated our CTS team on using acute pulmonary insufficiency which still gives you an MCC but avoids the complication code. The same with cardiogenic shock, you can't ignore it, but we do not count the use of vasopressors immediately following CABG (at least the first 24 hours) as shock, it is more of a transitional phase postoperative that would be expected. However PSI 4 excludes patients admitted with a primary MDC 5 (circulatory disorders) and a secondary dx of cardiogenic shock.

fishdl@shands.ufl.edu

Would you code ABLA in addition to anemia in chronic kidney disease if the physician response to a query states:  "Expected acute intraoperative blood loss anemia superimposed on anemia of chronic kidney disease"? 

vparent@emhs.org

We would yes.