Should Ulcerative Colitis be Coded?

bbogda@morrishospital.orgbbogda@morrishospital.org
in Clinical & Coding

Good Morning,

This patient was admitted with Afib and CHF.  Documented in the History and Physical is Ulcerative Colitis.  Documented In the Medication list is Purinethol.  This is being held this admission.  No other mention of it this admission.  I don't feel it should be coded because it is not being treated or monitored and he is not having issues.  Agree?
Thanks,
Betty

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Comments

  • lthompson5@ecommunity.comlthompson5@ecommunity.com
    I would look to see if increase resources are consumed due to the patient having this diagnosis.  Has the patient had diarrhea with frequent BM requiring staff assistance to bathroom or frequent cleaning the patient and change of gown/linen due to diarrhea?  Has there been a nutrition consult with regards to any special diet for UC?  If there is no 1.) monitoring 2.) Evaluating 3.) treatment 4.) increased resources 5.) increase in LOS then it wouldn't meet the definition of a secondary diagnosis.  Sometimes with these dx I do a deep dive and look at the nursing assessments and documentation to see if it affected their care.
  • sbrodie@hcpro.comsbrodie@hcpro.com
    this is one of those conditions that a physician has to take into consideration even when choosing current medications for their patients. the fact that they decided to hold the Purinethol is treatment. I also agree that checking the nursing notes is very important and hopefully they are documenting any change in bowel habits or any care given to prevent skin break down etc. type of diet is another form of treatment.
  • bbogda@morrishospital.orgbbogda@morrishospital.org
    That makes sense.  I agree!  Thank you.
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