POA status
Hi all,
I have a situation that seems to just not want to go away so I believe that I could use more opinions on the matter. We have a case where a 19 year old is involved in a MVC with significant injuries including to the head. On admission he has a IVH and frontal contusion but the CT scan does not reveal anything else. The next day, he has changes in mental status, is rescanned, and they note he has a 'new SAH'. This was coded as POA (N) making it a Hospital Acquired Injury. Obviously the injury was related to the MVC and did not occur in house but this is how a POA(N) ICH is tagged. The coders are saying that the POA status has to be (N) because of the verbiage of 'new'. Quality is saying that POA should be (Y).
Thoughts?
Thanks in advance.
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
I have a situation that seems to just not want to go away so I believe that I could use more opinions on the matter. We have a case where a 19 year old is involved in a MVC with significant injuries including to the head. On admission he has a IVH and frontal contusion but the CT scan does not reveal anything else. The next day, he has changes in mental status, is rescanned, and they note he has a 'new SAH'. This was coded as POA (N) making it a Hospital Acquired Injury. Obviously the injury was related to the MVC and did not occur in house but this is how a POA(N) ICH is tagged. The coders are saying that the POA status has to be (N) because of the verbiage of 'new'. Quality is saying that POA should be (Y).
Thoughts?
Thanks in advance.
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
Sent from my iPhone
On Apr 25, 2014, at 8:44 AM, CDI Talk wrote:
Hi all,
I have a situation that seems to just not want to go away so I believe that
I could use more opinions on the matter. We have a case where a 19 year old
is involved in a MVC with significant injuries including to the head. On
admission he has a IVH and frontal contusion but the CT scan does not
reveal anything else. The next day, he has changes in mental status, is
rescanned, and they note he has a ‘new SAH’. This was coded as POA (N)
making it a Hospital Acquired Injury. Obviously the injury was related to
the MVC and did not occur in house but this is how a POA(N) ICH is tagged.
The coders are saying that the POA status has to be (N) because of the
verbiage of ‘new’. Quality is saying that POA should be (Y).
Thoughts?
Thanks in advance.
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
I believe you can always query the physician for his clinical judgement as to determine whether a condition was/was not present on admission. The POA guidelines state on page 97 paragraph #4 that "these guidelines are not a substitute for provider's clinical judgment as to the determination of whether a condition was/was not present on admission.
I agree with you though....think it was POA.
Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com
Kerry
Kerry Seekircher, RN, CCDS, CDIP
Documentation Specialist Supervisor
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013
________________________________
I do find the formulation of a query a bit difficult in this case as far as wording. What do you think about the following.
Could you please clarify whether the subarachnoid hemorrhage likely is:
1. Present on admission but unidentified in initial CT scan
2. Not present on admission, developing during hospitalization
3. Unable to determine
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
something to that effect)?
Claudine Hutchinson RN (CDI)
The Children's Hospital at Saint Francis
chutchinson@saintfrancis.com
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, April 25, 2014 10:01 AM
To: Hutchinson, Claudine
Subject: RE:[cdi_talk] POA status
Of course I advocate for a query in this case. I think that if the coder
was comfortable coding the injury as POA(Y) that is ok, but I think that
if we were not comfortable with this, a query should have been
generated. I think before coding a HAC or HAI, we should be especially
diligent to make sure we are 100% sure of the status.
I do find the formulation of a query a bit difficult in this case as far
as wording. What do you think about the following.
Could you please clarify whether the subarachnoid hemorrhage likely is:
1. Present on admission but unidentified in initial CT scan
2. Not present on admission, developing during hospitalization
3. Unable to determine
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
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, April 25, 2014 6:55 AM
To: Kathryn Good
Subject: RE:[cdi_talk] POA status
I would agree that this was likely poa -would it be appropriate in this
case for you to ask for language clarifying evolving?
Kerry
Kerry Seekircher, RN, CCDS, CDIP
Documentation Specialist Supervisor
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013
________________________________
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, April 25, 2014 10:43 AM
To: Seekircher, Kerry
Subject: [cdi_talk] POA status
Hi all,
I have a situation that seems to just not want to go away so I believe
that I could use more opinions on the matter. We have a case where a 19
year old is involved in a MVC with significant injuries including to the
head. On admission he has a IVH and frontal contusion but the CT scan
does not reveal anything else. The next day, he has changes in mental
status, is rescanned, and they note he has a 'new SAH'. This was coded
as POA (N) making it a Hospital Acquired Injury. Obviously the injury
was related to the MVC and did not occur in house but this is how a
POA(N) ICH is tagged. The coders are saying that the POA status has to
be (N) because of the verbiage of 'new'. Quality is saying that POA
should be (Y).
Thoughts?
Thanks in advance.
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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----------------------------------------------------------------------
Saint Francis Health System intends this email only for the use of the person to whom it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If you have received this email in error, you are hereby notified that we do not consent to any reading, dissemination, distribution, or copying of this email and request you notify the sender immediately and destroy this transmission. Violators may be prosecuted under Federal law.
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
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, April 25, 2014 7:04 AM
To: Kathryn Good
Subject: RE: [cdi_talk] POA status
Maybe add to #2 "but suspected due to original/initial injury" (or something to that effect)?
Claudine Hutchinson RN (CDI)
The Children's Hospital at Saint Francis
chutchinson@saintfrancis.com
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, April 25, 2014 10:01 AM
To: Hutchinson, Claudine
Subject: RE:[cdi_talk] POA status
Of course I advocate for a query in this case. I think that if the coder was comfortable coding the injury as POA(Y) that is ok, but I think that if we were not comfortable with this, a query should have been generated. I think before coding a HAC or HAI, we should be especially diligent to make sure we are 100% sure of the status.
I do find the formulation of a query a bit difficult in this case as far as wording. What do you think about the following.
Could you please clarify whether the subarachnoid hemorrhage likely is:
1. Present on admission but unidentified in initial CT scan
2. Not present on admission, developing during hospitalization
3. Unable to determine
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
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, April 25, 2014 6:55 AM
To: Kathryn Good
Subject: RE:[cdi_talk] POA status
I would agree that this was likely poa -would it be appropriate in this case for you to ask for language clarifying evolving?
Kerry
Kerry Seekircher, RN, CCDS, CDIP
Documentation Specialist Supervisor
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013
________________________________
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, April 25, 2014 10:43 AM
To: Seekircher, Kerry
Subject: [cdi_talk] POA status
Hi all,
I have a situation that seems to just not want to go away so I believe that I could use more opinions on the matter. We have a case where a 19 year old is involved in a MVC with significant injuries including to the head. On admission he has a IVH and frontal contusion but the CT scan does not reveal anything else. The next day, he has changes in mental status, is rescanned, and they note he has a 'new SAH'. This was coded as POA (N) making it a Hospital Acquired Injury. Obviously the injury was related to the MVC and did not occur in house but this is how a POA(N) ICH is tagged. The coders are saying that the POA status has to be (N) because of the verbiage of 'new'. Quality is saying that POA should be (Y).
Thoughts?
Thanks in advance.
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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Note:
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________________________________
Saint Francis Health System intends this email only for the use of the person to whom it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If you have received this email in error, you are hereby notified that we do not consent to any reading, dissemination, distribution, or copying of this email and request you notify the sender immediately and destroy this transmission. Violators may be prosecuted under Federal law.
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s/p MVC.
IVH and frontal contusion on intial Head CT.
SAH noted on Head CT dated_______.
Based on your clinical judgement , please document whether SAH was:
- Evolving/ Present on Admission
- New finding / Not Present on Admission
- Unable to determine
- Other_____________
GL
On 4/25/14, CDI Talk wrote:
> Of course I advocate for a query in this case. I think that if the coder was
> comfortable coding the injury as POA(Y) that is ok, but I think that if we
> were not comfortable with this, a query should have been generated. I think
> before coding a HAC or HAI, we should be especially diligent to make sure we
> are 100% sure of the status.
> I do find the formulation of a query a bit difficult in this case as far as
> wording. What do you think about the following.
>
> Could you please clarify whether the subarachnoid hemorrhage likely is:
>
> 1. Present on admission but unidentified in initial CT scan
>
> 2. Not present on admission, developing during hospitalization
>
> 3. Unable to determine
>
> 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
>
> From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
> Sent: Friday, April 25, 2014 6:55 AM
> To: Kathryn Good
> Subject: RE:[cdi_talk] POA status
>
> I would agree that this was likely poa -would it be appropriate in this case
> for you to ask for language clarifying evolving?
> Kerry
>
> Kerry Seekircher, RN, CCDS, CDIP
> Documentation Specialist Supervisor
> Northern Westchester Hospital
> 400 East Main Street
> Mount Kisco, NY 10549
> Email: kseekircher@nwhc.net
> Phone: 914-666-1243
> Fax: 914-666-1013
>
>
>
>
> ________________________________
> From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
> Sent: Friday, April 25, 2014 10:43 AM
> To: Seekircher, Kerry
> Subject: [cdi_talk] POA status
>
> Hi all,
> I have a situation that seems to just not want to go away so I believe that
> I could use more opinions on the matter. We have a case where a 19 year old
> is involved in a MVC with significant injuries including to the head. On
> admission he has a IVH and frontal contusion but the CT scan does not reveal
> anything else. The next day, he has changes in mental status, is rescanned,
> and they note he has a 'new SAH'. This was coded as POA (N) making it a
> Hospital Acquired Injury. Obviously the injury was related to the MVC and
> did not occur in house but this is how a POA(N) ICH is tagged. The coders
> are saying that the POA status has to be (N) because of the verbiage of
> 'new'. Quality is saying that POA should be (Y).
>
> Thoughts?
>
> Thanks in advance.
>
> 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
>
>
>
>
> ---
>
> CDI Talk is offered for networking purposes. For official rules and
> regulations related to documentation and coding, please refer to your
> regulatory source.
>
>
>
> You are receiving this message as a member of CDI Talk as:
> kseekircher@nwhc.net
>
> If you would like to be removed from CDI Talk, please send a blank email to
>
> leave-cdi_talk-20097959.d65e69fc5d7027e8a40023ced48ccf9e@hcprotalk.com
>
> ---
>
> Copyright 2013
>
> HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
>
> ________________________________
> Note:
> This message is for the named person's use only. It may contain
> confidential, proprietary or legally privileged information. No
> confidentiality or privilege is waived or lost by any mistransmission. If
> you receive this message in error, please immediately delete it and all
> copies of it from your system, destroy any hard copies of it and notify the
> sender. You must not, directly or indirectly, use, disclose, distribute,
> print, or copy any part of this message if you are not the intended
> recipient. STELLARIS HEALTH NETWORK and any of its subsidiaries each reserve
> the right to monitor all e-mail communications through its networks.
>
> Any views expressed in this message are those of the individual sender,
> except where the message states otherwise and the sender is authorized to
> state them to be the views of any such entity.
>
>
>
> ---
>
> CDI Talk is offered for networking purposes. For official rules and
> regulations related to documentation and coding, please refer to your
> regulatory source.
>
>
>
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>
> Copyright 2013
>
> HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
>
> ---
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Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com
IMPORTANT: This communication contains information from Hays Medical Center which may be confidential and privileged. If it appears that the communication was addressed or sent to you in error, you may not use or copy this communication or any information contained therein, and you may not disclose this communication or the information contained therein to anyone else. In such circumstances, please notify me immediately by reply email or by telephone. Thank you.
----- Original Message -----
From: "CDI Talk"
To: "jolene file"
Sent: Friday, April 25, 2014 10:19:19 AM
Subject: Re: [cdi_talk] POA status
My version:
s/p MVC.
IVH and frontal contusion on intial Head CT.
SAH noted on Head CT dated_______.
Based on your clinical judgement , please document whether SAH was:
- Evolving/ Present on Admission
- New finding / Not Present on Admission
- Unable to determine
- Other_____________
GL
On 4/25/14, CDI Talk wrote:
> Of course I advocate for a query in this case. I think that if the coder was
> comfortable coding the injury as POA(Y) that is ok, but I think that if we
> were not comfortable with this, a query should have been generated. I think
> before coding a HAC or HAI, we should be especially diligent to make sure we
> are 100% sure of the status.
> I do find the formulation of a query a bit difficult in this case as far as
> wording. What do you think about the following.
>
> Could you please clarify whether the subarachnoid hemorrhage likely is:
>
> 1. Present on admission but unidentified in initial CT scan
>
> 2. Not present on admission, developing during hospitalization
>
> 3. Unable to determine
>
> 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
>
> From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
> Sent: Friday, April 25, 2014 6:55 AM
> To: Kathryn Good
> Subject: RE:[cdi_talk] POA status
>
> I would agree that this was likely poa -would it be appropriate in this case
> for you to ask for language clarifying evolving?
> Kerry
>
> Kerry Seekircher, RN, CCDS, CDIP
> Documentation Specialist Supervisor
> Northern Westchester Hospital
> 400 East Main Street
> Mount Kisco, NY 10549
> Email: kseekircher@nwhc.net
> Phone: 914-666-1243
> Fax: 914-666-1013
>
>
>
>
> ________________________________
> From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
> Sent: Friday, April 25, 2014 10:43 AM
> To: Seekircher, Kerry
> Subject: [cdi_talk] POA status
>
> Hi all,
> I have a situation that seems to just not want to go away so I believe that
> I could use more opinions on the matter. We have a case where a 19 year old
> is involved in a MVC with significant injuries including to the head. On
> admission he has a IVH and frontal contusion but the CT scan does not reveal
> anything else. The next day, he has changes in mental status, is rescanned,
> and they note he has a 'new SAH'. This was coded as POA (N) making it a
> Hospital Acquired Injury. Obviously the injury was related to the MVC and
> did not occur in house but this is how a POA(N) ICH is tagged. The coders
> are saying that the POA status has to be (N) because of the verbiage of
> 'new'. Quality is saying that POA should be (Y).
>
> Thoughts?
>
> Thanks in advance.
>
> 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
>
>
>
>
> ---
>
> CDI Talk is offered for networking purposes. For official rules and
> regulations related to documentation and coding, please refer to your
> regulatory source.
>
>
>
> You are receiving this message as a member of CDI Talk as:
> kseekircher@nwhc.net
>
> If you would like to be removed from CDI Talk, please send a blank email to
>
> leave-cdi_talk-20097959.d65e69fc5d7027e8a40023ced48ccf9e@hcprotalk.com
>
> ---
>
> Copyright 2013
>
> HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
>
> ________________________________
> Note:
> This message is for the named person's use only. It may contain
> confidential, proprietary or legally privileged information. No
> confidentiality or privilege is waived or lost by any mistransmission. If
> you receive this message in error, please immediately delete it and all
> copies of it from your system, destroy any hard copies of it and notify the
> sender. You must not, directly or indirectly, use, disclose, distribute,
> print, or copy any part of this message if you are not the intended
> recipient. STELLARIS HEALTH NETWORK and any of its subsidiaries each reserve
> the right to monitor all e-mail communications through its networks.
>
> Any views expressed in this message are those of the individual sender,
> except where the message states otherwise and the sender is authorized to
> state them to be the views of any such entity.
>
>
>
> ---
>
> CDI Talk is offered for networking purposes. For official rules and
> regulations related to documentation and coding, please refer to your
> regulatory source.
>
>
>
> You are receiving this message as a member of CDI Talk as:
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>
> If you would like to be removed from CDI Talk, please send a blank email to
>
> leave-cdi_talk-12649561.a6bbaf3538c19e934e5136fbd051a6b1@hcprotalk.com
>
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>
> Copyright 2013
>
> HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
>
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I also think it might help to speak to the MD to explain the circumstances of the query, as he/she will probably think (as do you) that the answer is obvious. At least that way, you maintain a good relationship and have the opportunity to explain the importance of making sure the poa is coded correctly.
If you have to do an email query-you might have better luck with the way the query was worded by GL-
- Evolving/ Present on Admission
- New finding / Not Present on Admission
- Unable to determine
- Other_____________
Kerry
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, April 25, 2014 11:26 AM
To: Seekircher, Kerry
Subject: Re: [cdi_talk] POA status
Very good concise query. In my opinion, either query would work. You could also verbal, so the physician understand the reason behind the query.
Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com
IMPORTANT: This communication contains information from Hays Medical Center which may be confidential and privileged. If it appears that the communication was addressed or sent to you in error, you may not use or copy this communication or any information contained therein, and you may not disclose this communication or the information contained therein to anyone else. In such circumstances, please notify me immediately by reply email or by telephone. Thank you.
----- Original Message -----
From: "CDI Talk"
To: "jolene file"
Sent: Friday, April 25, 2014 10:19:19 AM
Subject: Re: [cdi_talk] POA status
My version:
s/p MVC.
IVH and frontal contusion on intial Head CT.
SAH noted on Head CT dated_______.
Based on your clinical judgement , please document whether SAH was:
GL
On 4/25/14, CDI Talk wrote:
> Of course I advocate for a query in this case. I think that if the coder was
> comfortable coding the injury as POA(Y) that is ok, but I think that if we
> were not comfortable with this, a query should have been generated. I think
> before coding a HAC or HAI, we should be especially diligent to make sure we
> are 100% sure of the status.
> I do find the formulation of a query a bit difficult in this case as far as
> wording. What do you think about the following.
>
> Could you please clarify whether the subarachnoid hemorrhage likely is:
>
> 1. Present on admission but unidentified in initial CT scan
>
> 2. Not present on admission, developing during hospitalization
>
> 3. Unable to determine
>
> 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
>
> From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
> Sent: Friday, April 25, 2014 6:55 AM
> To: Kathryn Good
> Subject: RE:[cdi_talk] POA status
>
> I would agree that this was likely poa -would it be appropriate in this case
> for you to ask for language clarifying evolving?
> Kerry
>
> Kerry Seekircher, RN, CCDS, CDIP
> Documentation Specialist Supervisor
> Northern Westchester Hospital
> 400 East Main Street
> Mount Kisco, NY 10549
> Email: kseekircher@nwhc.net
> Phone: 914-666-1243
> Fax: 914-666-1013
>
>
>
>
> ________________________________
> From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
> Sent: Friday, April 25, 2014 10:43 AM
> To: Seekircher, Kerry
> Subject: [cdi_talk] POA status
>
> Hi all,
> I have a situation that seems to just not want to go away so I believe that
> I could use more opinions on the matter. We have a case where a 19 year old
> is involved in a MVC with significant injuries including to the head. On
> admission he has a IVH and frontal contusion but the CT scan does not reveal
> anything else. The next day, he has changes in mental status, is rescanned,
> and they note he has a 'new SAH'. This was coded as POA (N) making it a
> Hospital Acquired Injury. Obviously the injury was related to the MVC and
> did not occur in house but this is how a POA(N) ICH is tagged. The coders
> are saying that the POA status has to be (N) because of the verbiage of
> 'new'. Quality is saying that POA should be (Y).
>
> Thoughts?
>
> Thanks in advance.
>
> 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
>
>
>
>
> ---
>
> CDI Talk is offered for networking purposes. For official rules and
> regulations related to documentation and coding, please refer to your
> regulatory source.
>
>
>
> You are receiving this message as a member of CDI Talk as:
> kseekircher@nwhc.net
>
> If you would like to be removed from CDI Talk, please send a blank email to
>
> leave-cdi_talk-20097959.d65e69fc5d7027e8a40023ced48ccf9e@hcprotalk.com
>
> ---
>
> Copyright 2013
>
> HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
>
> ________________________________
> Note:
> This message is for the named person's use only. It may contain
> confidential, proprietary or legally privileged information. No
> confidentiality or privilege is waived or lost by any mistransmission. If
> you receive this message in error, please immediately delete it and all
> copies of it from your system, destroy any hard copies of it and notify the
> sender. You must not, directly or indirectly, use, disclose, distribute,
> print, or copy any part of this message if you are not the intended
> recipient. STELLARIS HEALTH NETWORK and any of its subsidiaries each reserve
> the right to monitor all e-mail communications through its networks.
>
> Any views expressed in this message are those of the individual sender,
> except where the message states otherwise and the sender is authorized to
> state them to be the views of any such entity.
>
>
>
> ---
>
> CDI Talk is offered for networking purposes. For official rules and
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>
>
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> ---
>
> Copyright 2013
>
> HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
>
> ---
> CDI Talk is offered for networking purposes. For official rules and
> regulations related to documentation and coding, please refer to your
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Note:
This message is for the named person's use only. It may contain confidential, proprietary or legally privileged information. No confidentiality or privilege is waived or lost by any mistransmission. If you receive this message in error, please immediately delete it and all copies of it from your system, destroy any hard copies of it and notify the sender. You must not, directly or indirectly, use, disclose, distribute, print, or copy any part of this message if you are not the intended recipient. STELLARIS HEALTH NETWORK and any of its subsidiaries each reserve the right to monitor all e-mail communications through its networks.
Any views expressed in this message are those of the individual sender, except where the message states otherwise and the sender is authorized to state them to be the views of any such entity.
See y'all TOMORROW!!! Can't believe the conference is finally here!
Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Cone Health at Alamance Regional
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com
"Leadership is solving problems. The day soldiers stop bringing you their problems is the day you have stopped leading them. They have either lost confidence that you can help or concluded you do not care. Either case is a failure of leadership."- Colin Powell
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, April 25, 2014 11:39 AM
To: Davis, Vicki S.
Subject: RE: [cdi_talk] POA status
Katy-
I also think it might help to speak to the MD to explain the circumstances of the query, as he/she will probably think (as do you) that the answer is obvious. At least that way, you maintain a good relationship and have the opportunity to explain the importance of making sure the poa is coded correctly.
If you have to do an email query-you might have better luck with the way the query was worded by GL-
- Evolving/ Present on Admission
- New finding / Not Present on Admission
- Unable to determine
- Other_____________
Kerry
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, April 25, 2014 11:26 AM
To: Seekircher, Kerry
Subject: Re: [cdi_talk] POA status
Very good concise query. In my opinion, either query would work. You could also verbal, so the physician understand the reason behind the query.
Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com
IMPORTANT: This communication contains information from Hays Medical Center which may be confidential and privileged. If it appears that the communication was addressed or sent to you in error, you may not use or copy this communication or any information contained therein, and you may not disclose this communication or the information contained therein to anyone else. In such circumstances, please notify me immediately by reply email or by telephone. Thank you.
----- Original Message -----
From: "CDI Talk"
To: "jolene file"
Sent: Friday, April 25, 2014 10:19:19 AM
Subject: Re: [cdi_talk] POA status
My version:
s/p MVC.
IVH and frontal contusion on intial Head CT.
SAH noted on Head CT dated_______.
Based on your clinical judgement , please document whether SAH was:
GL
On 4/25/14, CDI Talk wrote:
> Of course I advocate for a query in this case. I think that if the coder was
> comfortable coding the injury as POA(Y) that is ok, but I think that if we
> were not comfortable with this, a query should have been generated. I think
> before coding a HAC or HAI, we should be especially diligent to make sure we
> are 100% sure of the status.
> I do find the formulation of a query a bit difficult in this case as far as
> wording. What do you think about the following.
>
> Could you please clarify whether the subarachnoid hemorrhage likely is:
>
> 1. Present on admission but unidentified in initial CT scan
>
> 2. Not present on admission, developing during hospitalization
>
> 3. Unable to determine
>
> 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
>
> From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
> Sent: Friday, April 25, 2014 6:55 AM
> To: Kathryn Good
> Subject: RE:[cdi_talk] POA status
>
> I would agree that this was likely poa -would it be appropriate in this case
> for you to ask for language clarifying evolving?
> Kerry
>
> Kerry Seekircher, RN, CCDS, CDIP
> Documentation Specialist Supervisor
> Northern Westchester Hospital
> 400 East Main Street
> Mount Kisco, NY 10549
> Email: kseekircher@nwhc.net
> Phone: 914-666-1243
> Fax: 914-666-1013
>
>
>
>
> ________________________________
> From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
> Sent: Friday, April 25, 2014 10:43 AM
> To: Seekircher, Kerry
> Subject: [cdi_talk] POA status
>
> Hi all,
> I have a situation that seems to just not want to go away so I believe that
> I could use more opinions on the matter. We have a case where a 19 year old
> is involved in a MVC with significant injuries including to the head. On
> admission he has a IVH and frontal contusion but the CT scan does not reveal
> anything else. The next day, he has changes in mental status, is rescanned,
> and they note he has a 'new SAH'. This was coded as POA (N) making it a
> Hospital Acquired Injury. Obviously the injury was related to the MVC and
> did not occur in house but this is how a POA(N) ICH is tagged. The coders
> are saying that the POA status has to be (N) because of the verbiage of
> 'new'. Quality is saying that POA should be (Y).
>
> Thoughts?
>
> Thanks in advance.
>
> 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
>
>
>
>
> ---
>
> CDI Talk is offered for networking purposes. For official rules and
> regulations related to documentation and coding, please refer to your
> regulatory source.
>
>
>
> You are receiving this message as a member of CDI Talk as:
> kseekircher@nwhc.net
>
> If you would like to be removed from CDI Talk, please send a blank email to
>
> leave-cdi_talk-20097959.d65e69fc5d7027e8a40023ced48ccf9e@hcprotalk.com
>
> ---
>
> Copyright 2013
>
> HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
>
> ________________________________
> Note:
> This message is for the named person's use only. It may contain
> confidential, proprietary or legally privileged information. No
> confidentiality or privilege is waived or lost by any mistransmission. If
> you receive this message in error, please immediately delete it and all
> copies of it from your system, destroy any hard copies of it and notify the
> sender. You must not, directly or indirectly, use, disclose, distribute,
> print, or copy any part of this message if you are not the intended
> recipient. STELLARIS HEALTH NETWORK and any of its subsidiaries each reserve
> the right to monitor all e-mail communications through its networks.
>
> Any views expressed in this message are those of the individual sender,
> except where the message states otherwise and the sender is authorized to
> state them to be the views of any such entity.
>
>
>
> ---
>
> CDI Talk is offered for networking purposes. For official rules and
> regulations related to documentation and coding, please refer to your
> regulatory source.
>
>
>
> You are receiving this message as a member of CDI Talk as:
> kathryn.good@nahealth.com
>
> If you would like to be removed from CDI Talk, please send a blank email to
>
> leave-cdi_talk-12649561.a6bbaf3538c19e934e5136fbd051a6b1@hcprotalk.com
>
> ---
>
> Copyright 2013
>
> HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
>
> ---
> CDI Talk is offered for networking purposes. For official rules and
> regulations related to documentation and coding, please refer to your
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>
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> HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
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Also interested in others views.
Thanks,
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
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, January 19, 2016 3:26 PM
To: Salinas, Sharon
Subject: RE:[cdi_talk] POA status
Katy, I'm thinking it would be a progression, similar to a pressure ulcer stage II to III.. and POA. Be interesting to see how others view this.
Thanks Karen
Karen Bridgeman MSN, RN, CCDS
CDI Educator
Clinical Documentation Integrity
Medical University of South Carolina
Phone: 843.876.0333
Email: bridgema@musc.edu
Confidentiality Notice: If you have received this communication in error, please notify me immediately. The documents accompanying this facsimile/electronic transmission contain confidential information intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure. If the reader of this message is not the intended recipient, or an employee responsible for delivering the message to the intended recipient, you are hereby notified that any disclosure, dissemination, distribution, or copying of this communication is strictly prohibited.
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, January 19, 2016 5:57 PM
To: Bridgeman, Karen
Subject: [cdi_talk] POA status
I have a patient that had moderate malnutrition on admission which progressed to severe (complete duodenal obstruction d/t cancer). Patient was on TPN and eventually died during this admission.
In your assessment, does this fall into the category of an exacerbation like CHF where this would be POA(N) or in progression of renal failure staging where it would be POA(Y)?
Any relevant guidance would be appreciated.
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
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Thanks so much!
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