Clarification of Resp Failure

ddouthitddouthit
in CDI Talk Archive
Please offer opinion as to whether this consitutes conflicting/contrasting information and if further clarification is needed. Thinking about if we have to defend from RAC perspective.

Patient admitted with COPD Exacerbation and Resp. Failure per Hospitalist H&P.
Pulmonology consult states COPD Exacerbation with Acute on Chronic Respiratory Failure.
Hospitalist Discharge Summary states COPD Exacerbation with Chronic Respiratory Failure.
Patient placed on NRB on admit. ABG pH 7.270, PcO2 51.30 Po2 108.7.
Since d/c summary does not state a/c respiratory failure does this equal conflicting/contrasting information?

Thanks,
Dorie

Comments

  • mdomineseymdominesey
    edited May 2016
    If the Pulmonologist provides further clarification of the condition (i.e. Hospitalist writes "respiratory failure, Pulmonologist writes "acute on chronic respiratory failure") then record could stand. But, in this case, you have a conflicting diagnoses on the D/C Summary from the earlier H&P and consultant's note, so a query is necessary.

    HTH,

    Mark


    Mark N. Dominesey, RN, BSN, MBA, CCDS
    Sr. Clinical Documentation Improvement Specialist
    Sibley Memorial Hospital
    W: 202.660.6782

    http://www.sibley.org
  • dbutlerdbutler
    edited May 2016
    Agreed, but would consider carefully how word query options -- one to think about (as I suspect there is a real possibility what the hospitalist meant was at the time of discharge, the pt remains with chronic respiratory failure and the acute component of resp failure is now resolved):

    Acute Respiratory Failure, now resolved
    Chronic respiratory failure only
    both
    other
    clinically indeterminable

    Don
  • mdomineseymdominesey
    edited May 2016
    You bring up an excellent point Don! Yes, querying for this in the manner you suggest is by no means leading. This is one of those oppourtunities where a phone call/in person chat with the physician could be most helpful. I would definitely place a written query, but letting the physician know the reasoning behind the query is most helpful.

    MND
  • jolene.filejolene.file
    Hi Doris
    I have not been involved in a RAC review but as a seasoned coder, I know you may use the entire record to obtain diagnoses. If the patient meets the criteria for ac and chronic respiratory failure (518.84) and ac exacerbation of COPD (491.21), I don't know why you would not be able to code it. As I see it, the hospitalist did not say the patient did not have ac respiratory failure. Not all diagnoses
  • wchenneywchenney
    edited May 2016
    Can anyone share a salary range for Director of CDI at their facility?

    Thanks!


    Wendy R. Chenney RN BSN
    Clinical Documentation Coordinator
    (440) 743-4533
    Fax: (440) 743-4552
    Pager: (440) 675-5929
  • wchenneywchenney
    edited May 2016
    Management at my 300 bed community hosp is 80 - 84,000



    Wendy R. Chenney RN BSN
    Clinical Documentation Coordinator
    (440) 743-4533
    Fax: (440) 743-4552
    Pager: (440) 675-5929
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    I agree with Jolene - the RAC can be unreasonable sometimes, and there
    is an abundance of language in "Coding Clinic" clearly stating one must
    use the 'entire record' to code compliantly.


    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
  • wchenneywchenney
    edited May 2016
    Amen!

    Wendy R. Chenney RN BSN
    Clinical Documentation Coordinator
    (440) 743-4533
    Fax: (440) 743-4552
    Pager: (440) 675-5929
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