Calling on pediatric CDI

ddouthitddouthit
in Pediatrics
We received a denial for a newborn that was coded to a DRG 627 version 24.
Initial MD assessment stated faint I/VI SEM likely PDA. then a hand written physicin note on day 2 that looks like murmur resolved. A/P on discharge states term AGA infant.
Baby did not have echo, no referrel to cardiologist, vitals were normal, no oxygen, no NICU monitoring. He was only here for two days.
I have researched but must admit newborns diagnosis I am not very familiar with.
Question one: Can a PDA resolve in a 2 day stay?
Question two: If an appeal is warranted, what supporting documentation will be needed?

Any suggestions, education you would like to offer would be greatly appreciated.


Thank you for your help.


Dorie Douthit RHIT, CCS

Comments

  • kari.eskenskari.eskens
    edited May 2016
    Since it was stated as "likely PDA", this would be a probable diagnosis. Since it was ruled out during the course of the stay and no add'l testing or follow up was planned, I do not feel is not a codeable diagnosis. I would not recommend an appeal.

    Kari L. Eskens, RHIA
    BryanLGH Medical Center
    Coding & Clinical Documentation Manager

  • Linda_RhodesLinda_Rhodes
    edited May 2016
    Yes, a PDA can close in 2 days, however since there was no treatment, additional monitoring, use of resources, or extending of LOS, I would not appeal .


    Linda Rhodes RN, BSN, CCDS
    Manager Clinical Documentation Improvement
    New Hanover Regional Medical Center
    Wilmington, North Carolina
    Office # 910-815-5544
    Cell " 910-777-8344
    e-mail : linda.rhodes@nhrmc.org
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