Newborn Physical Exam findings
Hello everyone!
Do coders at your facility capture the below codes (no treatment)? It moves the DRG from 795 to 794. Because of this, we have to query if is clinically significant or not (if the provider does not specify it in his/her progress note):
- Hydrocele
- Congenital Penile Torsion (is there an specify degree in order to be coded?) -
- *Meconium passage
Thank you very much,
Cinthia Liriano, MD/FMG, CCDS
Comments
Yes they do at my facility, but we are having trouble with insurance. I would like to know what other facilities are doing.
Anything congenital per the coding guidelines and handbook indicate that it should be coded when documented by the provider, if they may have implications for future healthcare needs. With such short stays it would almost be impossible to state that the time of discharge that something congenital will absolutely not have any healthcare implications in the future. So i give them the options----may have implications for possible future healthcare needs and will not have any future healthcare needs.
When it comes to meconium passage it is technically in the newborn affected code set, so with that I will look for decels, cord gases, nicu attendance at delivery, things like to indicate that the baby was possibly in distress--and then send a query if it is considered clinically significant.