We had received a request for 87 records for complex review. I am in the process of reviewing all of those records to get a handle on our actual level of exposure.
I will be looking back from the perspective of whether or not the case was reviewed by CDI and then if a query was involved with the likely flag or if there was a risk we could have diminished if we had intervened -- but haven't looked at that aspect as of yet.
There was one clear pattern -- all of the 20+ spepsis with MCC cases were all 1-2 LOS (not including day of discharge), no expired pts. Don't see any clear pattern with the extensive / non-extensive procedures unrelated to pdx as of yet.
Don
Donald A. Butler, RN, BSN Manager, Clinical Documentation PCMH, Greenville NC dbutler@pcmh.com
Don If you are willing to share more of your findings and any impact the CDI might have had, please let us know. This might be a great learning opportunity for all. Thanks, Colleen Stukenberg MSN, RN, CMSRN, CCDS 815-599-6820 P Please consider the environment before printing this e-mail This e-mail message and any attached file(s) is intended for the use of the individual or entity to which it is addressed and may contain information that is privileged and confidential. If the reader of this message is not the intended recipient or an agent or employee of the intended entity, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received the message in error, please notify the sender immediately for instructions. Thank you.
I am in Region B and at this time we have not received any letters. We did have postings of 16 new complex reviews and 2 new automated reviews for a total of 14 automated reviews.
In the review of the Sepsis charts, did you see many charts with the coding of the MS DRG unspecified Sepsis with the principle diagnosis of SIRS. Debbie
I could be wrong, but I thought the code for SIRS can't be the PDx. According to the ICD-9-CM Official Guidelines for Coding and Reporting Effective October 1, 2009:
"The Coding of SIRS, sepsis and severe sepsis
The coding of SIRS, sepsis and severe sepsis requires a minimum of 2 codes: a code for the underlying cause (such as infection or trauma) and a code from subcategory 995.9 Systemic inflammatory response syndrome (SIRS). (i) The code for the underlying cause (such as infection or trauma) must be sequenced before the code from subcategory 995.9 Systemic inflammatory response syndrome (SIRS).
Codes from subcategory 995.9 can never be assigned as a principal diagnosis. A code should also be assigned for any localized infection, if present."
We are in region D with HealthData Insights our RAC. We received our first letter last week requesting 3 records for DRG validation (DRG 314 & DRG 314). It came to the general hospital address, not the PO box we specifically set up for RAC. Seems to be the norm for the letters not to be addressed correctly.
Laura Bohls, RN Clinical Documentation Specialist Prairie Lakes Healthcare Center
We're guessing due to only 1 MCC/CC. One of which is ESRD on dialysis, so they can't really argue with us there. We're a small rural facility (82 beds), so that's probably why we only had 3 records requested where others have had more requested.
We are in Region B and received our first RAC letter last Monday as well. The letter was not sent to our assigned post office box, but to the general hospital address. They requested 10 charts. 1 for Gastroenteritis w/MCC, 1 for CHF, 1 for Renal Failure, 5 for Septicemia w/ and w/o MCC, and 2 for Extensive OR procedure unrelated to principal dx. Our RACs team feels 50% of charts are appealable. The other 50% are for various reasons and not single source failure. Often times we do not have a discharge summary when charts are coded. I believe that we are going to find this issue as a challenge.
Has anyone heard from region A? We have yet to receive any complex review charts and would almost like to get started! The suspense and continual preparation are almost killing me! I have many concerns as to what RAC will find ...............
Thank you, Susan Tiffany RN, CDS Supervisor Clinical Documentation Program
Thank you for this information. We are still awaiting our first record requests. Lisa Taylor, RN Clinical Documentation Specialist Wooster Community Hospital Wooster, OH
We are Region A and waiting on pins and needles also.
Karen Frosch, CCS, CCDS Christiana Care - Performance Improvement Clinical Documentation Improvement Manager 302-733-4642 (office) 302-383-7177 (cell) "If you have built castles in the air, your work need not be lost; that is where they should be. Now put the foundations under them" - Henry David Thoreau
Yes....I'm am the RAC Liaison, the CDI Specialist and the ROI Specialist both are committee members.
Theresa Hall, RHIT, ACPAR Director of HIM/HIPAA Privacy Officer East Georgia Regional Medical Center P. O. Box 1048 1499 Fair Road Statesboro, GA 30458 T: 912-486-1761 F: 912-871-2388 theresa.hall@hma.com
That is the same here. Physicians have 30 days to complete their medical record (discharge summaries included). We cannot hold claims for 30 days or sometimes longer. We send a sample of our cases for pre-bill coding audit and our auditors never require a discharge summary.
Theresa Hall, RHIT, ACPAR Director of HIM/HIPAA Privacy Officer East Georgia Regional Medical Center P. O. Box 1048 1499 Fair Road Statesboro, GA 30458 T: 912-486-1761 F: 912-871-2388 theresa.hall@hma.com
We received a request today. They are asking for 75 records from 2005 through 2007.
Theresa Hall, RHIT, ACPAR Director of HIM/HIPAA Privacy Officer East Georgia Regional Medical Center P. O. Box 1048 1499 Fair Road Statesboro, GA 30458 T: 912-486-1761 F: 912-871-2388 theresa.hall@hma.com
Our experience (800+ bed tertiary care in Region C): 87 records requested (and now submitted), scattered dates. Groupings: % felt OK (most groupings to small to estimate with confidence) Major Chest Procedures 6 70% Other Resp OR 4 50% GI Surgical 5 80% GI Medical 9 30% Sepsis 29 50% Procedures Unrelated to PDX 33 80%
ALL of the sepsis were either 1 or 2 LOS, with MCC, no expired patients.
A common element among many of the other was a single cc -- an area that review showed some vulnerability.
The sepsis cases -- also some vulnerability -- mix of a few that simply were not clinically supported; documentation was not carried through the stay (HP, first PN, not second PN or DCS); other forms of poor documentation support (hind sight is 20/20).
The "other" drgs were actually pretty good.
After reviewing the records, feel that 60% were pretty solid, 20% anticipate a denial but feel had adequate grounds for a defense, 20% had poor defense. A few were obvious errors -- no defense at all.
Issues among coding and documentation are not strictly either or, but the leaning between the 2 areas was 50/50.
My estimate was a probable loss of 12% of the total DRG payments on all of these 87 cases.
1 or 2 might actually result in higher reimbursement, 1 had a second cc that was not initially coded (coded cc is at risk) & 1 had an MCC that was not coded (??) -- so will be interesting to see how those specific cases are handled.
Would love to hear what others find as they screen their records!!!!
Moving forward, providing better focus for ongoing concurrent reviews, will be developing a final validation pre-bill for all short stay sepsis; some educational emphasis on the other findings.
Sounds like there needs to be a discussion with someone. I am not sure if that is the person over your RAC region or who but it has been mentioned multiple times it is Oct 2007. I would find the supporting documentation of it and send it to them along with a phone call. How frustrating.
Colleen Stukenberg MSN, RN, CMSRN, CCDS 815-599-6820 P Please consider the environment before printing this e-mail
Not sure how I've saved any time -- everyone really needs to (at least at the start) do their own review of requested charts, see where your personal areas of weakness are and make plans or adjustments as appropriate (and hopefully share summary findings that might be relevant or helpful to others).
From our understanding the order must say "full inpatient admission" not regular admit, admit or inpatient. We have had several denials for improper admit order and since we implemented the above statement, the number of denials has significantly decreased
If any know answer or explanation of these topic would be appreciated. thanks,
MA
j. Define case-mix index and its relevance to CDI programs. k. Determine how a hospital’s individual case-mix index is calculated. l. Define when and how the IPPS is updated each year. m. Explain the goals and findings of the Recovery Audit Contractor (RAC) program. n. Recognize potential RAC risks.
Mohammad K. Ahmed, M.D, CCS Clinical Documentation Specialist Bronx Lebanon Hospital Center Health Information Management 1650 Grand Concourse Bronx, NY 10457 Phone: 718-518-5119 Fax: 718-518-5634 Email: mahmed1@bronxleb.org
CMI is the average of ther elative weights of the MS-DRGs in your patient paopulation. As relative weight increases, the CMI increases prportionally. To determin CMI for a hospital for a ma month, add the relative weight of each DRG and diveide by the number of patients. I beleive the IPPS is updated each Oct 1st. RAC imparcts CDI in that if a cc/MCC trends one way or antoher then theymay look at that area as not being doumented correctly. ie.e Inappropriate use of ARF. There are several areas that they monitor depending on the states that your in. It is based on Medicare rules and regulations. They look for errors in coding/billing that impact reimbursement. The CCDS exam guide is a great resource for these questions! Hope this helps.
This information is very typical of the content of the ACDIS CCDS Exam Study Guide -- a very good basis for learning a lot about Clinical Documentation Improvement -- & is also I believe covered in the ACDIS Clinical Documentation Specialist's Handbook.
Not sure which of the two I would suggest first -- both sit on my shelf and are referenced fairly often. If I had to choose, the Exam Study Guide has more core knowledge content, while the Handbook seems to have more industry/professional/bigger picture content.
you are right! I got this from study guide, but I could not find explanation.
Mohammad K. Ahmed, M.D, CCS Clinical Documentation Specialist Bronx Lebanon Hospital Center Health Information Management 1650 Grand Concourse Bronx, NY 10457 Phone: 718-518-5119 Fax: 718-518-5634 Email: mahmed1@bronxleb.org
My thought is that the treatment of the ABLA makes it codable. One might argue that the are many expected conditions secondary to a primary diagnosis. Good Luck!!!
I would argue this decision by the RAC because even thought it may be 'expected' that some patients may develop atelectasis, ileus, or acute blood loss anemia, not ALL pts do experience these.
However, if/when these conditions are present and meet the UHDDS Definition of a Reportable Condition, these should be coded to accurately reflect the acuity, ROM, complexity of care rendered, etc.
I interpret the following Coding Clinic as supportive of reporting 285.1 when appropriate. I would challenge the RAC to cite the authority for the decision on the basis of the official guidelines and I would include this referenced in C. Clinic.
AHA Coding Clinicâ for ICD-9-CM, 2Q 1992, Volume 9, Number 2, Pages 15-16
Question:
How do you code anemia which is diagnosed following a surgical procedure?
Answer:
It is difficult to respond to a question regarding postoperative anemia, since the answer is dependent on the documentation in the medical record. However, the following scenarios should help in deciding which code(s) to use:
1. If the physician documents postoperative anemia in the medical record, but does not label the condition as a complication, assign code 285.1, Acute posthemorrhagic anemia.
2. If the physician documents that a complication arose during or resulting from the procedure, such as an abnormal amount of blood loss, code 998.1, Hemorrhage or hematoma complicating a procedure, would be assigned. Code 285.1 may also be assigned.
3. If surgery results in an expected amount of blood loss and the physician does not describe the patient as having anemia or a complication of surgery, do not assign a code for the blood loss.
4. If the physician documents anemia in the medical record sometime after the operative episode, but does not state postoperative or complication, query the physician as to whether the anemia can be further specified. If more specific documentation can be obtained, refer to scenarios one and two above. If the anemia is not further specified, code 285.9, Anemia, unspecified, would be assigned.
5. One should not use blood transfusions as a definitive variable in determining whether or not to code a postoperative anemia as a complication. If the physician describes the patient as having a complication of surgery which is documented as anemia, the anemia can be coded as a complication regardless of whether or not a transfusion was given.
In addition, if there is normal blood loss during an operation, and the physician has not described the patient as having anemia or a complication of surgery, the lack of a blood transfusion reinforces that the blood loss should not be coded.
The above scenarios are strictly based on the documentation in the medical record.
I write all of the clinical arguments for our RAC appeals. If it were me, I would involve the patient's surgeon and get their input. The patient's surgeon would know best if this were an expected outcome. Keep in mind that RAC findings do not necessarily mean that the RAC is correct. Remember that 77% of RAC denials are overturned!
Kathy Kathy Shumpert, RN, CCDS
Clinical Documentation Improvement Specialist Howard Regional Health System Office 765-864-8754 Cell phone 765-432-3961 Fax 765-453-8152
When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela
I don't think the RAC is correct stating the basis for the denial is that this is 'expected'...the key point is the pt did have ABLA and it qualified for reporting.
An "Expected" outcome versus "unexpected' a factor when deciding how/when/if to report a condition with an ICD "Complication" Code.
But, ABLA is not a complication per coding and reporting guidelines - 285.1.
Paul Evans, RHIA, CCS, CCS-P Supervisor, Clinical Documentation Integrity, Quality Department California Pacific Medical Center 2351 Clay #243 San Francisco, CA 94115 Cell: 415.637.9002 Fax: 415.600.1325 Ofc: 415.600.3739
I would make sure your RAC knows that throughout this country diagnoses are determined by licensed providers such as MDs and NPs. We code and also query for additional clarification based on their diagnoses. When they answer and more specifically define the diagnoses it is coded based on their clinical judgment. The RAC is not a physician group brought in to audit physician medical decision making. The law states that we assign codes based on physician documentation. Not on what the RAC decides the diagnoses are. Don't forget the people hired by the RAC are coders and CDSs just like us.
Donna
Donna Kent, RN, BSN, CCDS Manager, Clinical Documentation Integrity Program Clinical Quality and Accreditation Torrance Memorial Medical Center ph.:310 784-6884 fax:310 784-6899 donna.kent@tmmc.com
Hi, I found the reference to Coding Clinic 2Q, 1992, Volume 9, Number 2, pages 15-16. But there seems to be a more recent clinic? Sorry, but my coding software wouldn't let me cut & paste it here, but check out Coding Clinic 1Q 2007, Volume 24, Number 1, Page 19-- which basically states: "when postoperative anemia is documented without specification of acute blood loss, code 285.9, Anemia, unspecified, is the default. Code 285.1, Acute posthemorrhagic anemia, should be assigned, when postoperative anemia is due to acute blood loss. Revisions were made to the Alphabetic Index in 2004, which direct the coder in the following manner:
Anemia postoperative due to blood loss 285.1 other 285.9"
Hope that helps? Becky Mann Sutter Solano Medical Center
Comments
Debbie
about
Thank you,
Susan Tiffany RN, CDS
I am in the process of reviewing all of those records to get a handle on our actual level of exposure.
I will be looking back from the perspective of whether or not the case was reviewed by CDI and then if a query was involved with the likely flag or if there was a risk we could have diminished if we had intervened -- but haven't looked at that aspect as of yet.
There was one clear pattern -- all of the 20+ spepsis with MCC cases were all 1-2 LOS (not including day of discharge), no expired pts.
Don't see any clear pattern with the extensive / non-extensive procedures unrelated to pdx as of yet.
Don
Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com
If you are willing to share more of your findings and any impact the CDI might have had, please let us know. This might be a great learning opportunity for all.
Thanks,
Colleen Stukenberg MSN, RN, CMSRN, CCDS
815-599-6820
P Please consider the environment before printing this e-mail
This e-mail message and any attached file(s) is intended for the use of the individual or entity to which it is addressed and may contain information that is privileged and confidential. If the reader of this message is not the intended recipient or an agent or employee of the intended entity, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received the message in error, please notify the sender immediately for instructions. Thank you.
did have postings of 16 new complex reviews and 2 new automated reviews
for a total of 14 automated reviews.
Don
Thank you,
Susan Tiffany RN, CDS
Supervisor
Clinical Documentation Program
Robert Packer Hospital & Corning Hospital
570-882-6094 pager 465
Fax 570-882-6768
Tiffany_Susan@guthrie.org
coding of the MS DRG unspecified Sepsis with the principle diagnosis of
SIRS.
Debbie
Michelle Clyne, RN, BS
Clinical Documentation Improvement Specialist
"The Coding of SIRS, sepsis and severe sepsis
The coding of SIRS, sepsis and severe sepsis requires a minimum of 2 codes: a code for the underlying cause (such as infection or trauma) and a code from subcategory 995.9 Systemic inflammatory response syndrome (SIRS).
(i)
The code for the underlying cause (such as infection or trauma) must be sequenced before the code from subcategory 995.9 Systemic inflammatory response syndrome (SIRS).
Codes from subcategory 995.9 can never be assigned as a principal diagnosis. A code should also be assigned for any localized infection, if present."
To read the complete guideline, go here;
http://www.cdc.gov/nchs/data/icd9/icdguide09.pdf - Begins on page 16 of 112.
These guidelines are also published in the front of every ICD-9 Manual.
This is a confusing subject, for sure. No wonder it's a RAC focus!
--Juan
w/out the hippa filter
Adrienne Baker, RN
Documentation Specialist
212-5245
212-9575 (pager)
N. Brunson,RHIA
Clinical Documentation Specialist'
Bay Medical Center
first letter last week requesting 3 records for DRG validation (DRG 314
& DRG 314). It came to the general hospital address, not the PO box we
specifically set up for RAC. Seems to be the norm for the letters not
to be addressed correctly.
Laura Bohls, RN
Clinical Documentation Specialist
Prairie Lakes Healthcare Center
Gina Spatafore, RN
Clinical Documentation Integrity Specialist
Waterbury Hospital
203 573 7647
charts and would almost like to get started! The suspense and continual
preparation are almost killing me! I have many concerns as to what RAC
will find ...............
Thank you,
Susan Tiffany RN, CDS
Supervisor
Clinical Documentation Program
Lisa Taylor, RN
Clinical Documentation Specialist
Wooster Community Hospital
Wooster, OH
Karen Frosch, CCS, CCDS
Christiana Care - Performance Improvement
Clinical Documentation Improvement Manager
302-733-4642 (office)
302-383-7177 (cell)
"If you have built castles in the air, your work need not be lost;
that is where they should be. Now put the foundations under them"
- Henry David Thoreau
Thank you,
Susan Tiffany RN, CDS
Supervisor
Clinical Documentation Program
Robert Packer Hospital & Corning Hospital
570-882-6094 pager 465
Fax 570-882-6768
Tiffany_Susan@guthrie.org
both are committee members.
Theresa Hall, RHIT, ACPAR
Director of HIM/HIPAA Privacy Officer
East Georgia Regional Medical Center
P. O. Box 1048
1499 Fair Road
Statesboro, GA 30458
T: 912-486-1761
F: 912-871-2388
theresa.hall@hma.com
don't be so anxious!!! Appealing is a very long process!!!
medical record (discharge summaries included). We cannot hold claims
for 30 days or sometimes longer. We send a sample of our cases for
pre-bill coding audit and our auditors never require a discharge
summary.
Theresa Hall, RHIT, ACPAR
Director of HIM/HIPAA Privacy Officer
East Georgia Regional Medical Center
P. O. Box 1048
1499 Fair Road
Statesboro, GA 30458
T: 912-486-1761
F: 912-871-2388
theresa.hall@hma.com
through 2007.
Theresa Hall, RHIT, ACPAR
Director of HIM/HIPAA Privacy Officer
East Georgia Regional Medical Center
P. O. Box 1048
1499 Fair Road
Statesboro, GA 30458
T: 912-486-1761
F: 912-871-2388
theresa.hall@hma.com
My understanding is RAC is limited to 1 Oct 2007 forward discharge dates!
Don
87 records requested (and now submitted), scattered dates.
Groupings:
% felt OK (most groupings to small to estimate with confidence)
Major Chest Procedures 6 70%
Other Resp OR 4 50%
GI Surgical 5 80%
GI Medical 9 30%
Sepsis 29 50%
Procedures Unrelated to PDX 33 80%
ALL of the sepsis were either 1 or 2 LOS, with MCC, no expired patients.
A common element among many of the other was a single cc -- an area that review showed some vulnerability.
The sepsis cases -- also some vulnerability -- mix of a few that simply were not clinically supported; documentation was not carried through the stay (HP, first PN, not second PN or DCS); other forms of poor documentation support (hind sight is 20/20).
The "other" drgs were actually pretty good.
After reviewing the records, feel that 60% were pretty solid, 20% anticipate a denial but feel had adequate grounds for a defense, 20% had poor defense. A few were obvious errors -- no defense at all.
Issues among coding and documentation are not strictly either or, but the leaning between the 2 areas was 50/50.
My estimate was a probable loss of 12% of the total DRG payments on all of these 87 cases.
1 or 2 might actually result in higher reimbursement, 1 had a second cc that was not initially coded (coded cc is at risk) & 1 had an MCC that was not coded (??) -- so will be interesting to see how those specific cases are handled.
Would love to hear what others find as they screen their records!!!!
Moving forward, providing better focus for ongoing concurrent reviews, will be developing a final validation pre-bill for all short stay sepsis; some educational emphasis on the other findings.
Don
Colleen Stukenberg MSN, RN, CMSRN, CCDS
815-599-6820
P Please consider the environment before printing this e-mail
You have saved us a great amount of time.
Ann Giuli RN, MPH
Core Measures/Documentation
Case Management Dept.
Stamford Hospital
203-276-7338
203-276-1000 Beeper #718
agiuli@stamhealth.org
Don
thanks,
MA
j. Define case-mix index and its relevance to CDI programs.
k. Determine how a hospital’s individual case-mix index is calculated.
l. Define when and how the IPPS is updated each year.
m. Explain the goals and findings of the Recovery Audit Contractor (RAC)
program.
n. Recognize potential RAC risks.
Mohammad K. Ahmed, M.D, CCS
Clinical Documentation Specialist
Bronx Lebanon Hospital Center
Health Information Management
1650 Grand Concourse
Bronx, NY 10457
Phone: 718-518-5119
Fax: 718-518-5634
Email: mahmed1@bronxleb.org
I am curious, where did this list come from? Looks like it came from
the CCDS Candidate Handbook?
http://www.hcpro.com/acdis/certification.cfm
This information is very typical of the content of the ACDIS CCDS Exam
Study Guide -- a very good basis for learning a lot about Clinical
Documentation Improvement -- & is also I believe covered in the ACDIS
Clinical Documentation Specialist's Handbook.
Can find them for purchase through the CDI Marketplace link:
http://www.hcmarketplace.com/T1_CDI/listings-Clinical-Documentation-Improvement.html
Not sure which of the two I would suggest first -- both sit on my shelf
and are referenced fairly often. If I had to choose, the Exam Study
Guide has more core knowledge content, while the Handbook seems to have
more industry/professional/bigger picture content.
Don
explanation.
Mohammad K. Ahmed, M.D, CCS
Clinical Documentation Specialist
Bronx Lebanon Hospital Center
Health Information Management
1650 Grand Concourse
Bronx, NY 10457
Phone: 718-518-5119
Fax: 718-518-5634
Email: mahmed1@bronxleb.org
Good Luck!!!
However, if/when these conditions are present and meet the UHDDS Definition of a Reportable Condition, these should be coded to accurately reflect the acuity, ROM, complexity of care rendered, etc.
I interpret the following Coding Clinic as supportive of reporting 285.1 when appropriate. I would challenge the RAC to cite the authority for the decision on the basis of the official guidelines and I would include this referenced in C. Clinic.
AHA Coding Clinicâ for ICD-9-CM, 2Q 1992, Volume 9, Number 2, Pages 15-16
Question:
How do you code anemia which is diagnosed following a surgical procedure?
Answer:
It is difficult to respond to a question regarding postoperative anemia, since the answer is dependent on the documentation in the medical record. However, the following scenarios should help in deciding which code(s) to use:
1. If the physician documents postoperative anemia in the medical record, but does not label the condition as a complication, assign code 285.1, Acute posthemorrhagic anemia.
2. If the physician documents that a complication arose during or resulting from the procedure, such as an abnormal amount of blood loss, code 998.1, Hemorrhage or hematoma complicating a procedure, would be assigned. Code 285.1 may also be assigned.
3. If surgery results in an expected amount of blood loss and the physician does not describe the patient as having anemia or a complication of surgery, do not assign a code for the blood loss.
4. If the physician documents anemia in the medical record sometime after the operative episode, but does not state postoperative or complication, query the physician as to whether the anemia can be further specified. If more specific documentation can be obtained, refer to scenarios one and two above. If the anemia is not further specified, code 285.9, Anemia, unspecified, would be assigned.
5. One should not use blood transfusions as a definitive variable in determining whether or not to code a postoperative anemia as a complication. If the physician describes the patient as having a complication of surgery which is documented as anemia, the anemia can be coded as a complication regardless of whether or not a transfusion was given.
In addition, if there is normal blood loss during an operation, and the physician has not described the patient as having anemia or a complication of surgery, the lack of a blood transfusion reinforces that the blood loss should not be coded.
The above scenarios are strictly based on the documentation in the medical record.
Kathy
Kathy Shumpert, RN, CCDS
Clinical Documentation Improvement Specialist
Howard Regional Health System
Office 765-864-8754
Cell phone 765-432-3961
Fax 765-453-8152
When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela
An "Expected" outcome versus "unexpected' a factor when deciding how/when/if to report a condition with an ICD "Complication" Code.
But, ABLA is not a complication per coding and reporting guidelines - 285.1.
Paul Evans, RHIA, CCS, CCS-P
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
are determined by licensed providers such as MDs and NPs. We code and
also query for additional clarification based on their diagnoses. When
they answer and more specifically define the diagnoses it is coded based
on their clinical judgment. The RAC is not a physician group brought in
to audit physician medical decision making. The law states that we
assign codes based on physician documentation. Not on what the RAC
decides the diagnoses are. Don't forget the people hired by the RAC are
coders and CDSs just like us.
Donna
Donna Kent, RN, BSN, CCDS
Manager, Clinical Documentation Integrity Program
Clinical Quality and Accreditation
Torrance Memorial Medical Center
ph.:310 784-6884 fax:310 784-6899
donna.kent@tmmc.com
I found the reference to Coding Clinic 2Q, 1992, Volume 9, Number 2, pages 15-16. But there seems to be a more recent clinic?
Sorry, but my coding software wouldn't let me cut & paste it here, but check out Coding Clinic 1Q 2007, Volume 24, Number 1, Page 19-- which basically states: "when postoperative anemia is documented without specification of acute blood loss, code 285.9, Anemia, unspecified, is the default. Code 285.1, Acute posthemorrhagic anemia, should be assigned, when postoperative anemia is due to acute blood loss. Revisions were made to the Alphabetic Index in 2004, which direct the coder in the following manner:
Anemia
postoperative
due to blood loss 285.1
other 285.9"
Hope that helps?
Becky Mann
Sutter Solano Medical Center