two questions...
1. Scenario: Patient is paraplegiac and was treated (debridement/closure) of stage 4 ischial pressure ulcer years ago. The ulcer recently reopened and patient comes in for scheduled debridement and flap placement. OP note dx is Stage 4 pressure ulcer and this is stated throughout. Is it most correct to assign the chronic ulcer code or the pressure ulcer code with the stage4 as the MCC?
2. Patient comes in with dizziness and blurred vision and malignant HTN. Pt has hx of prior hypertensive bleed a month ago. Extensive workup is performed to determine if there is continued bleed. MRI shows that there is no continued bleed but does show the chronic bleed that was seen a month prior. Provider documents:
basal ganglia hemorrhagic stroke hx 2/2 HTN
-MRI on admit w/no acute changes---resolving compared to 12/10 and 12/15 MRI
-apprec neurology input---rec CT head if neg ok to resume asa---see next section
-no further sx of dizzy/blurry vison all 2/2 to uncontrolled HTN
-no focal neuro deficits today--1/17
Discharge summery lists: "Relatively recent basal ganglia hemorrhagic stroke in 12/2013." in the problem list and in the narrative states "She was seen by neurology. She did not have a recurrent stroke."
Should the stroke (431) be coded?
This two are really giving me a run for my money...
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
2. Patient comes in with dizziness and blurred vision and malignant HTN. Pt has hx of prior hypertensive bleed a month ago. Extensive workup is performed to determine if there is continued bleed. MRI shows that there is no continued bleed but does show the chronic bleed that was seen a month prior. Provider documents:
basal ganglia hemorrhagic stroke hx 2/2 HTN
-MRI on admit w/no acute changes---resolving compared to 12/10 and 12/15 MRI
-apprec neurology input---rec CT head if neg ok to resume asa---see next section
-no further sx of dizzy/blurry vison all 2/2 to uncontrolled HTN
-no focal neuro deficits today--1/17
Discharge summery lists: "Relatively recent basal ganglia hemorrhagic stroke in 12/2013." in the problem list and in the narrative states "She was seen by neurology. She did not have a recurrent stroke."
Should the stroke (431) be coded?
This two are really giving me a run for my money...
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Comments
Scenario #1 - Decubitus ulcer as prin dx with stage 4 as secondary - CC 1st Qtr, 1996 page 15 and CC 3rd Qtr, 1990 p 15 both offer advice on a similar scenarios.
Scenario #2 - I don't think so. An acute bleed was ruled out after study and she has no deficits due to the previous bleed. V12.54 would be more appropriate in my opinion.
Interested to see what others think...
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org
secondary as it's still showing up and still going to be a consideration
for treatment (if it was a a year and 2 weeks ago I would not think it
would be coded.
(I thought the same as other on first situation).
Ann
I would assign Decubitus ulcer ischium stage 4 for the first scenario.
Scenario #2
I do not think you can assign a current stroke code for this patient. There is no supporting clinical indicators to support a current CVA. Does patient have residual symptoms from previous CVA? Might could get a late effect of cva and residuals out of it
Dorie Douthit RHIT,CCS
AHIMA-Approved ICD-10-CM/PCS Trainer
ddouthit@stmarysathens.org
No, the patient has no residual deficits and the dizziness/blurred vision they had on presentation is determined to be related to the patients Hypertension
Ann,
This is where the struggle lies. Yes, the patient had a resolving stroke from a month ago. The reason for the complete workup was because of this history. But nothing acute was found. This is the sole MCC on this record and I am auditing, hence the concern.
Thank you everyone for your thoughts!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Debbie Smith RN, CCDS
UT Southwestern University Hospitals
Debbie Smith RN, CCDS
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404