Coding is subjective - My coworkers and I are stuck on the Principal Diagnosis

avita · May 2021

Ambiguous documentation exists in the record including, as follows:

H&P: presented today for an outpatient visit with orthopedic surgery after undergoing hemiarthroplasty of her right hip approximately 2 weeks ago. Patient reports over the past week she has noted some purulent drainage from her right hip with an open wound. Right hip pyogenic arthritis. Sepsis secondary to septic arthritis right hip.

ID: Right hip infection d/t hardware. Ortho: Wound dehiscence R hip, question acute prosthetic joint infection.

QUERY QUESTION: Please clarify the cause(s) of the septic arthritis to the right hip joint. QUERY RESPONSE: "septic arthritis right hip 2/2 right hip wound dehiscence" Please comment below on what the principal diagnosis should be

morris-jeff@CooperHealth.edu · June 2021

Coding is subjective - My coworkers and I are stuck on the Principal Diagnosis

avita May 20, 2021

Ambiguous documentation exists in the record including, as follows:
H&P: presented today for an outpatient visit with orthopedic surgery after undergoing hemiarthroplasty of her right hip approximately 2 weeks ago. Patient reports over the past week she has noted some purulent drainage from her right hip with an open wound. Right hip pyogenic arthritis. Sepsis secondary to septic arthritis right hip.
ID: Right hip infection d/t hardware.                                                                                                       Ortho: Wound dehiscence R hip, question acute prosthetic joint infection.
QUERY QUESTION: Please clarify the cause(s) of the septic arthritis to the right hip joint.            QUERY RESPONSE: "septic arthritis right hip 2/2 right hip wound dehiscence"                                  Please comment below on what the principal diagnosis should be

Was the hardware infected? Removed?

Coding is subjective - My coworkers and I are stuck on the Principal Diagnosis

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