"the principle diagnosis is...."
Full of questions this morning!
We are having some doctors now document what the Pdx is. It just started happening and I am assuming they are using some sort of new documentation assistant tool that is prompting them for this. Often this is being documented in the H&P and often carried through to later documentation.
Of course the problem with this is that physicians (for the most part) do not understand sequencing guidelines so what they think is the Pdx may not be what we think it should be. For example: the patient may have come in with multiple issues that meet PDX criteria but they select the one that carries a lower RW. Or the patient may come in with sepsis 2/2 to PNA and they say the Pdx is PNA.
In cases where there is clear sequencing guidelines (sepsis must be sequences first) I am confident coding will code according to the guidelines rather than the what the MD says. However, in other circumstances, like multiple possible PDX options, I am concerned this documentation may be problematic.
What are your thoughts on this? Are other providers documenting this way?
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
We are having some doctors now document what the Pdx is. It just started happening and I am assuming they are using some sort of new documentation assistant tool that is prompting them for this. Often this is being documented in the H&P and often carried through to later documentation.
Of course the problem with this is that physicians (for the most part) do not understand sequencing guidelines so what they think is the Pdx may not be what we think it should be. For example: the patient may have come in with multiple issues that meet PDX criteria but they select the one that carries a lower RW. Or the patient may come in with sepsis 2/2 to PNA and they say the Pdx is PNA.
In cases where there is clear sequencing guidelines (sepsis must be sequences first) I am confident coding will code according to the guidelines rather than the what the MD says. However, in other circumstances, like multiple possible PDX options, I am concerned this documentation may be problematic.
What are your thoughts on this? Are other providers documenting this way?
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
I feel that if we talk to our Docs about 'coding', they shut down - I understand why this is so. I shut down when IT tells me I can't log in because my 'baud rate' is impaired, too.
PE
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
Thanks for the help!
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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Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
Deanne Wilk, BSN, RN, CCDS, CCS
AHIMA approved ICD-10-CM/PCS Trainer
Clinical Documentation Improvement and Inpatient Coding Manager
HIMS Department
Wellspan Good Samaritan Hospital
4th & Walnut Sts
Lebanon, PA 17042
dwilk@gshleb.org
Phone: 717-270-7582
Cell: 717-580-1436
Does anybody have any suggestion?
Anna Rozhkovskaya, RHIT, CCS, CCS-P
Manager, Clinical Documentation Improvement
Memorial Healthcare System