Integral to disease process?
Good Morning -
I recently saw a thread re: jaundice and patients with liver disease. To code or not to jaundice? I have tried to search high and low to obtain any literature that supports jaundice is either integral or not integral to the disease process and have come up with nothing. I feel it is considered a symptom. Example: Patient admitted with painless jaundice 2/2 to ETOH hepatitis. What is the nation doing in terms of coding this CC as a secondary diagnosis?
Other example is a patient admitted with GBM. Physician clearly documented cerebral edema and supportive treatment of IV Mannitol with close monitoring. I have worked at two hospitals as a CDI specialist. One hospital would take the MCC as a secondary diagnosis and education was provided that it is not considered integral to the disease process, I am also aware there are coding clinics to support this. The other hospital states that it is integral to the disease process and will not code it. What is the rest of the nation doing?
Appreciate any feedback!
Thank you
L.F. RN, BSN CCDS
I recently saw a thread re: jaundice and patients with liver disease. To code or not to jaundice? I have tried to search high and low to obtain any literature that supports jaundice is either integral or not integral to the disease process and have come up with nothing. I feel it is considered a symptom. Example: Patient admitted with painless jaundice 2/2 to ETOH hepatitis. What is the nation doing in terms of coding this CC as a secondary diagnosis?
Other example is a patient admitted with GBM. Physician clearly documented cerebral edema and supportive treatment of IV Mannitol with close monitoring. I have worked at two hospitals as a CDI specialist. One hospital would take the MCC as a secondary diagnosis and education was provided that it is not considered integral to the disease process, I am also aware there are coding clinics to support this. The other hospital states that it is integral to the disease process and will not code it. What is the rest of the nation doing?
Appreciate any feedback!
Thank you
L.F. RN, BSN CCDS
Comments
Dawn
Mary L. Snook RN-BC
Clinical Documentation Specialist
Medical Information Services
Gail Eaton RN PCCN CDS
Clinical Documentation Specialist
St Joesph Health
2700 Dolbeer, Eureka, Ca, 95501
Office: 707-445-8121 ext 7555
Cell: 707-267-0279
The growth of the GBM can cause compression of the brain but not necessarily cerebral edema....these are two different things.
Hope this helps,
Gail
Gail Eaton RN PCCN CDS
Clinical Documentation Specialist
St Joseph Health
2700 Dolbeer, Eureka, Ca, 95501
Office: 707-445-8121 ext 7555
Cell: 707-267-0279