DVT/PE POA Status

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
Hi all,

We are becoming more involved in PSI's and I am in the process of performing a retro audit to identify query and coding opportunities. One of the things I am noting is that when DVT/PE's are identified 'incidentally' during the admission, they are assigned POA(N). These are cases where the study was done for a separate reason, there was no symptomology related to the PE/DVT. It seems to me, that we do not know when this actually occurred. Would it be appropriate to query the MD for POA status in these cases. I realize they also may not know which would result in a coding of POA (W).

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

  • vanessa.falkoffvanessa.falkoff
    edited April 2016
    Hi,

    Thanks for the heads up for something to look for. I agree - query for the W.

    Vanessa Falkoff RN
    Clinical Documentation Improvement Coordinator
    University Medical Center of Southern Nevada
    1800 W Charleston Blvd
    Las Vegas, NV
    vanessa.falkoff@umcsn.com
    office 702-383-7322

    Compassion * Accountability * Respect * Integrity


  • ggoodman@virginiahospitalcenter.comggoodman@virginiahospitalcenter.com
    edited April 2016
    I would Query.
    :)
    Greta


  • arozhkovskayaarozhkovskaya
    edited April 2016
    I agree, you cannot assume whether this was POA or not. Therefore, would post the query to the doc.
    Anna

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Thanks everyone. I was assuming this was appropriate but wanted to make sure I wasn't missing something in that assessment.

    I appreciate your feedback.

    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

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