If an MD documents it, I use it. Also if there is reference to an increased need for pulmonary toilette, or use of Incentive Spirometry, something like that. If it is only referenced in a CXR, for instance, and there is no other information referencing it, I have been told by the coders not to take it, and also not to query for it, based on CXR info alone, with no related treatment.
I queried atelectasis today. I referenced a low-grade temp, elevated WBC and diminished breath sounds to go with the CXR report of atelectasis. I agree with Becky that you can't just go off the CXR report.
One fairly specific area where we don't pick up -- our professional coders & CT surgeons have maintained that it is an expected condition (approaching 100%) for post-op patients. Only picked up if there is more than the usual tx / monitoring in those cases.
I have always wondered this-- If it is expected do that mean that all patient have that diagnosis? If all patients don't have that diagnosis and were not coding (because it is expected-- how do you really know who aquired atelectasis and who did not? Requesting some clarity.
Good point. No matter what is written in the chart, if there is not treatment to back it up, it should not be coded. UHDDS defines other diagnosis as: all conditions that coexist at the time of admission, that develop subsequently,or that affect the treatment received and/or the length of stay. And further defines complication/comorbidity as a condition that will increase the LOS by at least 1 day.
Thank you, Susan Tiffany RN, CDS Supervisor Clinical Documentation Program
Good question without any good answers. The only time I would see it as new is if the radiologist has compared the x-ray with previous images and documents an "interval development". Otherwise, it's next to impossible to determine if it's new onset. I also disagree, that all patients would have that diagnosis.
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"Anyone who has never made a mistake has never tried anything new." -Albert Einstein
Combination of a couple of things -- the great majority of pts have post-op radiology findings, all of incentive spirometry / pulmonary toilet, physicians sometimes will document (but not always)...... In the past, when one particular CDS was trying to query for this condition -- sometimes would get documentation, sometimes physician response was that it was a normal finding for their post-op patients....when documented and not significant resource utilization (more than what every pt gets as far as monitoring & pulmonary toilet and no significant change of resp status), coding professionals did not want to code.
Now we only pursue this documentation (or other resp status documentation) when the resources or status is different than the norm for the post-op valve or cabg pt.
As far as expected -- I personally feel that it does not mean 100%, but rather a very high percentage....gut feel is probably 90%....similar to acute COPD and acute resp distress not being coded separately.
Robert -- my comments & our experience ONLY applies to CT surgery (valve & cabg) pts and the perspective / thoughts of that specific group of surgeons.
Other post op pts and service lines are quite different and we do see and capture actelectasis in those populations.
Susan, I have never heard that a CC/MCC has to increase the LOS by at least one day. Then we should never take ESRD/HD as an MCC because they don't stay longer for it, but it certainly uses up our resources!
It is listed under definition of a comorbid condition. I do believe that an ESRD patient will take a longer time period and more resources to recover than some one who is not ESRD. Comorbidity - Preexisting condition that, because of its presence with a specific diagnosis, causes an increase in length of stay by at least one day in approximately 75 percent of the cases. Coders' Desk Reference by Ingenix
Thank you, Susan Tiffany RN, CDS Supervisor Clinical Documentation Program Robert Packer Hospital & Corning Hospital
Comments
Renee
Don
treatment to back it up, it should not be coded.
UHDDS defines other diagnosis as: all conditions that coexist at the time
of admission, that develop subsequently,or that affect the treatment
received and/or the length of stay. And further defines
complication/comorbidity as a condition that will increase the LOS by at
least 1 day.
Thank you,
Susan Tiffany RN, CDS
Supervisor
Clinical Documentation Program
new is if the radiologist has compared the x-ray with previous images
and documents an "interval development". Otherwise, it's next to
impossible to determine if it's new onset. I also disagree, that all
patients would have that diagnosis.
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"Anyone who has never made a mistake has never tried anything new."
-Albert Einstein
In the past, when one particular CDS was trying to query for this condition -- sometimes would get documentation, sometimes physician response was that it was a normal finding for their post-op patients....when documented and not significant resource utilization (more than what every pt gets as far as monitoring & pulmonary toilet and no significant change of resp status), coding professionals did not want to code.
Now we only pursue this documentation (or other resp status documentation) when the resources or status is different than the norm for the post-op valve or cabg pt.
As far as expected -- I personally feel that it does not mean 100%, but rather a very high percentage....gut feel is probably 90%....similar to acute COPD and acute resp distress not being coded separately.
Don
Other post op pts and service lines are quite different and we do see and capture actelectasis in those populations.
Don
Robert
"To climb a steep hill requires a slow pace at first."
Debbie
Renee
an ESRD patient will take a longer time period and more resources to
recover than some one who is not ESRD.
Comorbidity - Preexisting condition that, because of its presence with a
specific diagnosis, causes an increase in length of stay by at least one
day in approximately 75 percent of the cases. Coders' Desk Reference by
Ingenix
Thank you,
Susan Tiffany RN, CDS
Supervisor
Clinical Documentation Program
Robert Packer Hospital & Corning Hospital