complications
Wondering if the following example should generate a query or be coded as a complication:
The synovial cyst was found to be densely adherent to the dura. During manipulation of the cyst a small durotomy was encounterd.
Wondering if the following example should generate a query or be coded as a complication:
The synovial cyst was found to be densely adherent to the dura. During manipulation of the cyst a small durotomy was encounterd.
Comments
Tears resulting from manipulations in the setting of dense adhesions are stated in Coding Clinic, and elsewhere, as not uncommon, unavoidable, or inherent to some procedures.
I'd query for that reason.
Yep, the surgeon is doing the best they can to tell us that this was unavoidable but just needs some education on the "buzz words".
Jeff
Does anyone out there have issues with Coding capturing adverse drug effect codes with 'hyperglycemia due to steroids' or 'hypokalemia due to diuretics' and, if so, what are you doing about it?
I have read coding clinics that address inherent conditions, has anyone come across any related to meds?
We have instructed our MD's to enter 'as expected with this medication' however, it is still captured as T code, and unfortunately - will be captured in our data as a complication.
Any advice welcome.
Sharon
"hypokalemia due to diuretics' is simply not enough information for me to make a judgement call. This is nuanced. Was it mild and self limiting? Then no, neither a dx nor an adverse effect code would be appropriate to add. Was it severe, symptomatic, with treatment required? The Dx may be reportable. Did it happen well above what SHOULD have occurred or what was expected? The adverse effect code may now be reportable.
Be aware of anyone making blanket declarations about "all hyponatremia due to any diuretics" as that advice is simply over simplified and over stated.
Determining the clinical significance of hyperglycemia would require a similiar case by case analysis.