Drop in hemoglobin
This goes out to any coders in the group. Patient with principal diagnosis "UGIB unspecified". Physician documents "acute drop in H/H" and the lab fingings and treatment support the documentation.
Now, we use the 3M encoder. When you enter "drop" the next screen gives option of "Hematocrit (precipitous) and "Hemoglobin". If you select "Hemoglobin" It gives you 790.01. This code will move the DRG because it is a "cc". When you reference the code book it shows
790.01 Precipitous drop in hematocrit
Drop in Hematocrit
Drop in Hemoglobin
can this be coded based on the documentation in the chart?
I have been told it cannot because it is only a lab finding. If this is correct, why would it be listed in the coding book? I know it could be a query opportunity for perhaps "acute blood loss anemia", but if the documentation will will give you a "cc" as it is written a query may not be necessary unless you are wanting to capture SOI.
I reaaly just wander if "acute drop in H/H" can be coded as documented. Please advise.
Now, we use the 3M encoder. When you enter "drop" the next screen gives option of "Hematocrit (precipitous) and "Hemoglobin". If you select "Hemoglobin" It gives you 790.01. This code will move the DRG because it is a "cc". When you reference the code book it shows
790.01 Precipitous drop in hematocrit
Drop in Hematocrit
Drop in Hemoglobin
can this be coded based on the documentation in the chart?
I have been told it cannot because it is only a lab finding. If this is correct, why would it be listed in the coding book? I know it could be a query opportunity for perhaps "acute blood loss anemia", but if the documentation will will give you a "cc" as it is written a query may not be necessary unless you are wanting to capture SOI.
I reaaly just wander if "acute drop in H/H" can be coded as documented. Please advise.
Comments
Don
code using the same info that you did and yes it is indeed a CC. I would
take the CC if - as Don says - there is no other mention of Anemia.
Then I would query for the ABLA.
It's supported by clinical info. The physician documented it in the
chart. It is a CC.
N. Brunson, RHIA
Clinical Documentation Specialist
Bay Medical Center
contraindication and blood cannot be given?
N. Brunson, RHIA
Clinical Documentation Specialist
Bay Medical Center
Does that make sense?
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
Explained better than I did earlier, Thanks!
As far as the reluctance to code the 790.01 -- at my facility there are dynamic discussions among the coding community as well as with the CDI's about what the coder's feel comfortable to code and support by ICD9 and coding clinic.
Part of the job I think.
Some research into the index and coding clinic might help to engage in a dialog.
Don
A bit of inconsistency, but my coders here have confirmed this with me when I asked the question before.
Robert
"To climb a steep hill requires a slow pace at first."