"In the setting of": how do you handle this documentation?
Hello,
Our CDS group has been told by our coders that they cannot code a cause/effect relationship based on 'in the setting of' and I wanted to see how everyone else deals with this.
For example: UTI in the setting of foley catheter
We saw all the coding clinics regarding probable/suspected, evidence of, etc but no mention of this verbiage which our docs tend to use frequently. Our policy has been to query in these situations, but I cannot find a clinic/guideline to back up that decision. We started thinking this might be one of those situations where we do it 'because we always have done it this way'.
Thanks in advance,
Amy
Our CDS group has been told by our coders that they cannot code a cause/effect relationship based on 'in the setting of' and I wanted to see how everyone else deals with this.
For example: UTI in the setting of foley catheter
We saw all the coding clinics regarding probable/suspected, evidence of, etc but no mention of this verbiage which our docs tend to use frequently. Our policy has been to query in these situations, but I cannot find a clinic/guideline to back up that decision. We started thinking this might be one of those situations where we do it 'because we always have done it this way'.
Thanks in advance,
Amy
Comments
I think due to would be more compliant linking terms and wouldn't assign a code for CAUTI based on this verbiage. We would also query if I see "in the setting". We also query when we see terms like "covering for" (" Ex. will give Vancomycin to cover for staph PNA"). Interested to see what other's do.
Jeff
Great question: I agree one should query for cause & effect. This is our current practice.
Paul Evans, RHIA, CCDS
I would feel the same. To me, this is nonspecific documentation and requires clarification.
Katy'
Cathy Seluke
Jackie Touch