v-tach
Okay...physician verbally told my co-worker that CAD (which pt is currently being treated for)is reason for v-tach, but doesn't document that in record. What is the rationale for V-tach as the PDX instead of CAD? I am having a hard time explaining this to her. I believe what is confusing her is that angina/cp in pt with known CAD goes to CAD as PDX in some instances. I really appreciate all your thoughts!
Comments
CAD. The CAD may be causing/contributing to the V-TACH, but the
V-TACH is the chief reason for the admission and the condition that was
directly treated.
Even if the MD had documented the CAD as the cause for V-TACH, the PDX
is still the V-TACH as this is the 'acute' condition causing the
admission and responsible for the utilization of resources.
Paul Evans, RHIA, CCS, CCS-P
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
Gross hematuria due to prostate cancer
Coding Clinic, Second Quarter 2010 Page: 3 Effective with discharges: July 7, 2010
Question:
A patient, who is currently under treatment for prostate cancer, was admitted for gross hematuria with a significant drop in hemoglobin. The patient had been unable to pass urine and was only passing frank blood and clots. While in the hospital, 12 units of blood were transfused, and bladder irrigation was started and continued until the urine was clear for approximately 12 hours. What is the principal diagnosis for this admission?
Answer:
Assign code 599.71, Gross hematuria, as principal diagnosis. In this case, treatment was not directed at the malignancy. Assign code 185, Malignant neoplasm of prostate, as an additional diagnosis. Based on the medical documentation, the patient was admitted for gross hematuria.
The basic rule for designating principal diagnosis is the same for neoplasm as for any other condition; that is, the principal diagnosis is the condition found after study to have occasioned the current admission or encounter. There is no guideline that indicates that a code for the malignancy takes precedence. Because the principal diagnosis may be difficult to determine, the focus of treatment can often be used as a guide. Refer to the Official Guidelines for Coding and Reporting, Selection of Principal Diagnosis, Section II, B. for additional information.
Code 599.71 may also be used as a secondary code if the malignancy meets the definition of principal diagnosis and the hematuria was also being managed.
Renee
Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center
CC 2Q1997:
Question:
There still appears to be confusion regarding coronary artery disease (CAD) and angina when the patient is admitted with unstable angina and no further testing is done to confirm the presence of CAD. What documentation needs to be present to establish a "link"?
Answer:
As stated in Coding Clinic Second Quarter 1994, page 15, "a diagnostic test need not be performed during that admission for the diagnosis of coronary artery disease to be established. If the physician cites CAD as the underlying cause of the unstable angina, the CAD is listed as the principal diagnosis." If there is documentation of previous testing to confirm the presence of CAD, then this is the link and the CAD should be listed first. If however, the physician states that the angina is due to another condition (i.e, stenosis), then code that condition as the principal diagnosis. Assign a code for the angina as an additional diagnosis.
Renee
Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center
Renee
Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center