FW:
Hello!
Can someone please enlighten me about "resolved-in-ED" issues.
I have a coder asking me to look at a case where a patient comes in to ED SOB with dyspnea, pursed lip breathing....Blood sugar in 517 and insulin gtt is started in ED and patients second assessment in ED is with "no further stated SOB". NO resources were used for the Acute resp failure ONCE PT WAS ADMITTED, -no Solumedrol, no O2 etc. However, the Adult ICU Admission orders state "Acute Resp Failure".
LET ME THROW ANOTHER KINK IN THIS...The H&P clearly documents "ACUTE RESP FAILURE RESOLVED ONCE INSULIN DRIP STARTED". WHICH WAS STARTED IN ED!
I am not clear on issues where you have a diagnosis that was basically resolved in ED. There were few to no Clinical indicators other than I already stated plus resp 24, pH 7.51, Pco2 26, p02 27
Can anyone tell me what they think? I think the issue with this case is that the H&P. I DON'T THINK YOU CAN USE THE ACUTE RESP FAILURE AS THE MCC. The Payer wants to use DRG 638. The original coder used 189 but I don't think the resp failure bought the bed as it was resolved by the time of admission.
Help! I agree with DRG 638...but I say NO MCC for acute resp failure!
Juli Bovard RN CDS
Rapid City Regional Hospital
Juli Bovard RN CDS
Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
719-4390 (work)
786-2677 (cell)
"No Limit to Better......"
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"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
Comments
What services were directed toward the Acute Respiratory Failure in the ED? Just insulin gtt? Were there clinical indicators for respiratory failure present in the ED? If patient received treatment in ED for Acute Respiratory Failure then I would think it would meet criteria for a secondary diagnosis. If a patient for a CVA with syncope and had fallen sustaining a laceration that was repaired in ED and the only documentation of the laceration and repair were in the ED documentation, as a coder you would still pick this up when assigning codes.
Dorie Douthit, RHIT,CCS
I think the presenting dx would be the failure if that's why they came to the ED. However, the admitting dx is what they were admitted for which would be the DM. if the resp issues did not direct any care during the inpatient visit, I wouldn't use it as an MCC.
I have absolutely NOTHING to back this up though
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
I am interested in what others have to say about this..
Mark
Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Clinical Documentation Excellence
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital
Information Technology
5255 Loughboro Rd NW
Washington DC, 20016-2695
W: 202.660.6782
F: 202.537.4477
mdominesey@sibley.org
[cid:image002.gif@01CD4EFB.AD3F7F70]
http://www.sibley.org
Dorie Douthit, RHIT,CCS
definitely reportable, so long as it meets the UHDDS definition. From
a 'coding' standpoint, we most definitely code conditions that are
treated by the ED staff and resolved prior to arrival on the floor/unit.
Patients may be in the ED for hours, allowing the MD staff time to
treat successfully conditions that are 'resolved' upon arrival to the
floor.
P. Evans, RHIA, CCDS
Paul Evans, RHIA, CCS, CCS-P, CCDS
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
evanspx@sutterhealth.org
Good response Paul, it's good to hear from a coder on this!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Following dietary indiscretion, a patient with compensated congestive
heart failure developed paroxysmal nocturnal dyspnea, orthopnea, and
pedal edema leading to increased respiratory distress. In the emergency
room the patient was found to be in cardiogenic pulmonary edema and
respiratory failure and was subsequently intubated in the emergency
room. The patient was admitted and treated for congestive failure. No
myocardial infarction was found.
Principal diagnosis:
428.0 Congestive heart failure
Additional diagnosis:
518.81 Respiratory failure
In this example, the congestive heart failure had become acute and
required immediate hospital care. The associated development of
respiratory failure in this case is an additional complicating factor,
but is not the condition that occasioned the admission and should not be
designated as the principal diagnos
Paul Evans, RHIA, CCS, CCS-P, CCDS
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
evanspx@sutterhealth.org
Juli
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
that strong'. So, there is that as a part of the conundrum -
Personally, I would issue a query to 'confirm' the acute respiratory
failure' noted in the ED.
I am not comfortable coding 518.81 if no respiratory interventions
documented .....not logical.
Paul Evans, RHIA, CCS, CCS-P, CCDS
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
evanspx@sutterhealth.org
Dorie Douthit, RHIT,CCS
We recently had a case that I wanted to pull my hair out about. The patient had PNA and the MD documents on day 1 "Hypoxia (acute respiratory failure per coder)"!!! I don't know what the MD was thinking writing this at all. There was no query placed on the chart but CDI's attend rounds and maybe the CDI asked if the patient had resp failure? This then gets copied/pasted throughout the admission. By "coder" of course she means CDI though. This was not caught concurrently and made it to coding where I was then contacted asking if it should be coded. The patient also never really had Resp failure (in my opinion).
Ugh...
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Dorie Douthit, RHIT,CCS
Dorie
(ARF, Sepsis, Encephalopathy)
'Condition (X) was noted on admission per the H&P, but no further
documentation is provided.
On admission the patient's (insert pertinent findings, lab values) were
__, orders for ____fluids/antibiotics/oxygen on ___date(s). Can you
clarify if the patient was being treated for ________?
Please indicate if ____________was present, has been successfully
treated and is resolved versus was ruled out.
Paul Evans, RHIA, CCS, CCS-P, CCDS
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
evanspx@sutterhealth.org
Thanks for the query idea, but for our institution we would never be allowed to use this query. We were advised from HCPRO and our Consultant group that queries should not pose a question with the answer in the question-and/or be able to be answered with a "yes or no" response. Our queries give the Clinical Indicators, Resources used and asked for clarification and then give a multitude of choices-dependent upon the diagnosis in question-and always include "other" or "unable to determine" in the query choices! This way we are not LEADING in any way. Hope this helps!
Juli Bovard RN CDS
Rapid City Regional Hospital
The query basically states the dx as stated in the documentation and any clinical indicators. It then asks if this dx was relevant, treated, monitored during this admission or not.
I'm still not 100% sure about it but....
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Also, this is a bit different situation in that the record has already clearly stated something such as "ARF' or Sepsis....so, this is not leading given the language is already clearly documented in the record. I would be asking the Attending to make the final call.
Thanks.
Paul
Paul Evans, RHIA, CCS, CCS-P, CCDS
************************************************************************
************************************************************************
*******************************************************
Dear Physician/PA/NP:
____________________________________________________________________ or
other responsible provider:
For accurate coding and severity-of-illness compilation, this query is
directed to you. When responding to this query, please exercise your
independent professional judgment. The fact that a question is asked
does not imply that any particular answer is desired or expected.
On_________ documentation in the
__________________________________section of the medical record states:
If in agreement, please document your concurrence with this diagnosis;
otherwise, please document a clarified diagnosis. If appropriate,
please include the severity, type or nature and any suspected
etiologies.
.
CDI Specialist/Coder: _________________________________
Date:_____________ Time: _______________
PHYSICIAN/PA/NP Response:
Clarification of findings:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
______
No significance Cannot be
determined
Physician/PA/NP Printed
Name:___________________________________________________________________
___
Physician/PA/NP Signature:
_____________________________________________Date:
__________Time:_______
Addressographor patientsticker
Paul Evans, RHIA, CCS, CCS-P, CCDS
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
evanspx@sutterhealth.org
Paul Evans, RHIA, CCS, CCS-P, CCDS
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
evanspx@sutterhealth.org
been superceded by Coding Clinic 2005 1st Qtr. Respiratory failure can
be used as principal dx with acute non-respiratory conditions depending
on the circumstances of admission.
Respiratory failure w/ nonrespiratory conditions - guidelines
Coding Clinic, Second Quarter 1991 Page: 3 to 5 Effective with
discharges: April 1, 1991
Related Information
Sequencing of Respiratory Failure in Association with Nonrespiratory
Conditions
Note from 3M:
This advice has been superceded by that issued in First Quarter 2005,
page 3.
The Central Office has continued to receive numerous requests regarding
the sequencing of respiratory failure. The following instruction has
been developed by the Cooperating Parties to provide clarification. Some
of the principles outlined below are consistent with previously
published advice, and some contain revised information. Please review
carefully these principles along with the accompanying examples.
Code 518.81, Acute respiratory failure, may be assigned as a principal
diagnosis when it is the condition established after study to be chiefly
responsible for occasioning the admission to the hospital, and the
selection is supported by the Alphabetic Index and Tabular List.
However, chapter-specific coding guidelines (obstetrics, poisoning, HIV,
newborn) that provide sequencing direction take precedence. Respiratory
failure may be listed as a secondary diagnosis if it occurs after
admission.
When a patient is admitted with respiratory failure and another acute
condition, (e.g., myocardial infarction, cerebrovascular accident), the
principal diagnosis will not be the same in every situation. Selection
of the principal diagnosis will be dependent on the circumstances of
admission. If both the respiratory failure and the other acute condition
are responsible for occasioning the admission to the hospital, the
guideline regarding two or more diagnoses that equally meet the
definition for principal diagnosis (Section II, C,) may be applied in
these situations.
The advice above supercedes guideline #1 and guideline #2, previously
published in Coding Clinic, Second Quarter 1991, page 3.
Having said that, I agree that respiratory failure would not be the
principal dx given the info in original email.
Sharon Salinas, CCS
Barlow Respiratory Hospital
213-250-4200 Extension 3336
Dorie
Good morning! I agree with you...It is the "gray" area again we all know is out there concerning this career field and Query issues! When I started our program 3 years ago we had only 2 queries, one generic and one for POA. We now have 18 Standard Diagnosis queries (CHF, Sepsis ect), 2 generic (POA, Blank)......We are always struggling for verbiage on queries where we don't have the template! It would be so much easier if things were set in stone and not so "gray"!
Juli
Agreed...and we also have the "discharge diagnosis" issues. We have "Hospitalists" here and so often, a patient can ostensibly be here for 5 days and NEVER see the same doctor twice. It is a constant issue with the documentation to then get the provider to carry forward the previous doctors diagnosis-and eventually diagnosis' often just fade out of the chart. The original reason for admission OFTEN has resolved by dc and other diagnosis are being carried forward. The discharge summary then does not state the reason they were even admitted! WE CONSTANTLY educate, but it is even getting worse now with a hybrid chart. Suggestions? Does anyone else run into this?
Juli Bovard RN CDS
Judi Bates RN, BSN, CCDS
Our Lady of Lourdes Medical Center
CDI Specialist
856-757-3161
Beeper 66x2906
My only solution has been to query for it, and I really don't know of a better way to handle it. We have provided info/tips on what should be in a D/C summery but we still come across this issue fairly regularly....
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
In the case where a diagnosis was left off the discharge summary (especially if principal, MCC, or CC) we ask the physician to go back and address the diagnosis as an addendum to the discharge summary.
Usual query: Medical record reflects diagnosis of ____________. Can you addend d/c summary to reflect diagnosis __________ ruled in, ruled out, resolved, improving, unable to determine.
Dorie
Cindy
I too code the whole record, but have had the "privilege" of defending many RACS since taking on new roll and CC/MCC documented and discussed in the d/c summary make you less open to RAC denials.
Dorie
Cindy
Dorie
Cindy
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
From your mouth to the physician's ears.
Dorie
Cindy
I think this thread speaks to an all too often problem faced in the
coding, CDI, and compliance world: major conditions are apparently
present and valid, but not carried through into the summary. This
creates monumental problems for the coder as one can argue the
conditions may have been ruled out. I have been a consultant, coder,
CDI supervisor for 20+ years, and I have coded as a consultant in
literally hundreds of hospitals, and this is an issue at most of the
places I have worked. =20
=20
We constantly restate to our staff the importance of the D/C summary,
citing the pertinent JCAHO requirements to document all 'significant'
conditions as well as our supporting Medical Staff-By-Laws with the same
statement. =20
=20
I am not the coding manager at this site, but the CDI mgr, so I can't
directly answer the question put forth - 'do your coders coding a
condition if not in the summary' - but, I think the answer is it
depends, unfortunately.=20
=20
When I do code, I always 'vet or check' the typical signs, symptoms,
treatment of any 'major' condition affecting the DRG - I do this because
I have come to believe I need to code 'defensively'.
=20
As our CDI concurrently reviews our sample of cases, we use the
attached form to remind the 'current' attending to speak to the apparent
ATN, Sepsis, PNA, severe malnutrition, etc, that is stated on
date___________, but not repeated. Ideally, this would be repeated in
the summary - if not, I am of the opinion a positive response to this
query would justify coding of the condition in question given it asked
for CONFIRMATION specifically for condition 'X".
=20
However, I am certain the RAC will make counter arguments - =20
=20
Paul
=20
=20
=20
Paul Evans, RHIA, CCS, CCS-P, CCDS
=20
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
evanspx@sutterhealth.org
for common diagnoses, and we also have some generic forms as well, for
common situations.
Verbiage selection is always difficult as an 'effective' query can't be
'leading' - it is difficult to achieve balance in that regard. The
issue of the 'disappearing 'diagnosis is problematic 'everywhere' - or
so it seems to me.
Regarding the 'gray' areas of coding, I think certain issues will always
remain due to the complexity of the CDI and Coding professions.
But, one of my concerns is with the RAC as my opinion is that the RAC
too often either does not know how to apply the coding and compliance
rules, or they are very, very Draconian during their reviews. It is
noteworthy that 43% of the RAC findings are successfully appealed - in
my mind; this means they were only accurate for 57% of these compliance
reviews. I have been a Compliance Auditor, and my company was paid
nicely to perform validation reviews and the results were vetted - my
accuracy rate was expected to be 98%.
Paul
Paul Evans, RHIA, CCS, CCS-P, CCDS
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
evanspx@sutterhealth.org
AMEN!
juli
Good morning.....while I KNOW the statement in my head, can anyone tell me where to find the "paragraph" that basically says "Medicare finds nothing wrong with the implementation of CDI programs or hiring CDI to increase specificity in charting"? I thought it was in the AHIMA brief, but cannot locate it anywhere in my information. (Those words in quotations aren't the exact wording-but something to that effect). Thanks in advance for your help
Juli Bovard RC CCDS
Rapid City Regional Hospital
Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
719-4390 (work)
786-2677 (cell)
"No Limit to Better......"
[CCDS_pin_1inch]
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
Source: Federal Register, Vol. 72, No. 162, Wed. Aug. 22, 2007,
Rules and Regulations, pp. 47180-47181.
Hope this helps, Joyce
"As we stated in the FY 2008 IPPS final rule with comment period, we do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment as long as the coding is fully and properly supported by documentation in the medical record."
Federal Register/Vol.73, No. 161/Tues. Aug. 19, 2008/Rules & Regulations, pgs.48448
Sharon
Sharon Cooper, RN-BC, CCS, CCDS, CDIP
AHIMA-Approved ICD-10-CM/PCS Trainer
Owensboro Medical Health System
Manager Clinical Documentation & Appeals
P.O. Box 20007
Owensboro, KY 42304-0007
(270) 688-1277 Office
(270) 316-9088 Cell
(270) 688-2737 Fax
sharon.cooper@omhs.org
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