Coding of "Spells" Ruled Out...

The following is from a d/c summary of a patient that was admitted for spells and had video eeg monitoring...


HOSPITAL COURSE: This patient was admitted for video EEG monitoring to determine the electrical nature of the spells. The patient had no spells for the entire admission, despite sleep deprivation. The patient was on no anti-seizure medications at the time, and there was no change in her home medications. She was recorded for the duration of her hospital stay on video and EEG. The results of the video EEG via post hoc analysis will be available post discharge.

What would be the pdx for this 4 day stay? Would we go with the 780.39 "spells" or would it be better to be coded as a V71.89 "obs and eval for suspected condition not found".

Thanks for any thoughts you might have!

Angela Susott CCS, CPC, CCDS

Comments

  • edited May 2016
    I had no idea that the medical community was still using the term
    "spells".

    Donna Kent, RN, BSN, CCDS
    Manager, Clinical Documentation Integrity Program
    Clinical Quality and Accreditation
    Torrance Memorial Medical Center
    ph.:310 784-6884 fax:310 784-6899
    donna.kent@tmmc.com
  • edited May 2016
    "In the south" we often see this described as "fell out". Great opportunity for a query!!

    Linda Rhodes RN, BSN, CCDS
    Manager Clinical Documentation Improvement
    New Hanover Regional Medical Center
    Wilmington, North Carolina
    Office # 910-815-5544
    Cell " 910-777-8344
    e-mail : linda.rhodes@nhrmc.org
  • edited May 2016
    Don't want my Docs finding out they can use "spells"....:) sounds like should have been Observation... Or at least a "possible" diagnosis for a 4 day stay... :(
  • edited May 2016
    Yep. Especially on Sundays -- apparently an Eastern Carolina Church can be a very unhealthy place to be, I hear EMS called out for unresponsive at churches all the time. (I moonlight at a small, rural ED on many Sundays).

    Don
  • edited May 2016
    So by "spells" it should really be coded as "Spiritually moved." Only in the Bible Belt... :)
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