Coding CC/MCC 's that have resolved in ETR
Greetings -
In an effort to capture medical necessity- can you capture those conditions that have been treated and resolved prior to inpatient admission ? EX - ETR Treatment and monitoring not captured in the inpatient account-
Thank you -
In an effort to capture medical necessity- can you capture those conditions that have been treated and resolved prior to inpatient admission ? EX - ETR Treatment and monitoring not captured in the inpatient account-
Thank you -
Comments
Yes - admission starts in the ED - the ED notes should be used for coding purposes as a progress note - that is - code any conditions that qualify for reporting, noted clearly with 'clinical support'. If conflict or dissonance, query Attending. When a patient is admitted via the ED, this is reported as a part of the inpatient encounter.
P. Evans CCDS
has a hard time rendering this documentation in the inpatient assessment and plan. Typically, they site that they did not see the patient-
I wonder if we need to create a query that will assist them with documentation that will outline the clinical significance of the condition-
Thank you !!
“It is the responsibility of the attending physician to gather and collate all of the findings from
consultants and other providers involved in the care of the patient. the plan of care is based on
the attending physician’s evaluation, interpretation,and collation of all the findings (i.e. pathology, radiology,And laboratory results)
3rd Quarter 2006, page 26-