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
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
"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
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
Don