need help
Good morning all,
1) We have a dilemma with the following questions. I wonder if anyone has a definition they are using to differentiate the skin tear from a decubitus ulcer? We have some physicians who are calling a skin tear a decubitus ulcer.
2) Also, if any one queries for the 'pregnancy is incidental to the admission diagnoses'? We have met resistance from the coding department on this one.
1) About whether someone has a definition of a skin tear? (& how it relates to a pressure ulcer)
2) How they differentiate something that is incidental to pregnancy, versus having pregnancy be the primary dx.
I would appreciate any help you can offer.
pam
[cid:image004.png@01CE0F46.65ED4920]
Pamela Parris,RN
Clinical Documentation Integrity
MUSC
Charleston, South Carolina 29425
Pager: 12295
(843) 792-3442
MAIN HOSPITAL
Confidentiality Notice: If you have received this communication in error, please notify the sender immediately. The documents accompanying this facsimile/electronic transmission contain confidential information intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure. If the reader of this message is not the intended recipient, or an employee responsible for delivering the message to the intended recipient, you are hereby notified that any disclosure, dissemination, distribution, or copying of this communication is strictly prohibited.
1) We have a dilemma with the following questions. I wonder if anyone has a definition they are using to differentiate the skin tear from a decubitus ulcer? We have some physicians who are calling a skin tear a decubitus ulcer.
2) Also, if any one queries for the 'pregnancy is incidental to the admission diagnoses'? We have met resistance from the coding department on this one.
1) About whether someone has a definition of a skin tear? (& how it relates to a pressure ulcer)
2) How they differentiate something that is incidental to pregnancy, versus having pregnancy be the primary dx.
I would appreciate any help you can offer.
pam
[cid:image004.png@01CE0F46.65ED4920]
Pamela Parris,RN
Clinical Documentation Integrity
MUSC
Charleston, South Carolina 29425
Pager: 12295
(843) 792-3442
MAIN HOSPITAL
Confidentiality Notice: If you have received this communication in error, please notify the sender immediately. The documents accompanying this facsimile/electronic transmission contain confidential information intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure. If the reader of this message is not the intended recipient, or an employee responsible for delivering the message to the intended recipient, you are hereby notified that any disclosure, dissemination, distribution, or copying of this communication is strictly prohibited.
Comments
How it was explained to me is that it really is only going to end up out of the pregnancy DRG's if absolutely NOTHING is done for pregnancy. So if there was ANY monitoring done for the pregnancy, which there almost always is, it will end up in the pregnancy DRG's. So even if the admission was psych related or something, they probably are still going to end up there. Because of this, we have not pushed for this documentation. I'm curious to hear if others have been doing the same.
AS for the pressure/ulcer skin tear issue, have you contacted the wound care nurses and asked them for guidance? That would be my first step. Then I would try to get some education out to the Docs. We have not had this issue so I don't have any definitions prepared but it seems like it would be fairly simple.
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
pam
[cid:image002.png@01CE0F48.08EFFA90]
Pamela Parris,RN
Clinical Documentation Integrity
MUSC
Charleston, South Carolina 29425
Pager: 12295
(843) 792-3442
MAIN HOSPITAL
Confidentiality Notice: If you have received this communication in error, please notify the sender immediately. The documents accompanying this facsimile/electronic transmission contain confidential information intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure. If the reader of this message is not the intended recipient, or an employee responsible for delivering the message to the intended recipient, you are hereby notified that any disclosure, dissemination, distribution, or copying of this communication is strictly prohibited.
I can speak to the pregnancy question. In discussions with coding and our consulting company we have been cautioned regarding the use of querying for "pregnancy incidental to the diagnosis". In the majority of patient scenarios, the pregnancy is considered when making decisions regarding anesthesia, medications, diagnostic testing, etc.. We have found that few providers would say that they did not consider the pregnancy while making decisions for the treatment of the patient (even in some of the minor diagnoses). A few exceptions have been when the pregnancy was discovered on admission (only a couple weeks pregnant) and the physician documented it was an incidental finding. It doesn't seem fair most of the time as the Pregnancy DRG's are low weighted, but it is what it is. Good luck!
Linda
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
Thank you,
Angie McKee, RHIT, CCDS, CCS, CCS-P
AHIMA Approved ICD 10 Trainer
Clinical Documentation Specialist
Performance Improvement
University Hospital
1350 Walton Way,
Augusta, Ga 30901
angelamckee@uh.org
pam
[cid:image001.png@01CE0F51.B29B68A0]
Pamela Parris,RN
Clinical Documentation Integrity
MUSC
Charleston, South Carolina 29425
Pager: 12295
(843) 792-3442
MAIN HOSPITAL
Confidentiality Notice: If you have received this communication in error, please notify the sender immediately. The documents accompanying this facsimile/electronic transmission contain confidential information intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure. If the reader of this message is not the intended recipient, or an employee responsible for delivering the message to the intended recipient, you are hereby notified that any disclosure, dissemination, distribution, or copying of this communication is strictly prohibited.
I would guess (and only a guess), there would almost never be a circumstance that if a patient is pregnant that your principal diagnosis would be anything other than a pregnancy code.
Dorie Douthit, RHIT,CCS
.
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
pam
[cid:image001.png@01CE0F52.D337FDC0]
Pamela Parris,RN
Clinical Documentation Integrity
MUSC
Charleston, South Carolina 29425
Pager: 12295
(843) 792-3442
MAIN HOSPITAL
Confidentiality Notice: If you have received this communication in error, please notify the sender immediately. The documents accompanying this facsimile/electronic transmission contain confidential information intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure. If the reader of this message is not the intended recipient, or an employee responsible for delivering the message to the intended recipient, you are hereby notified that any disclosure, dissemination, distribution, or copying of this communication is strictly prohibited.
I know that MDs were not considering the babe in utero as they performed heroic measures to treat and save mother. It coded to pregnancy complications. She was in and out of hospital after her D/C to rehab for bone flap replacements, etc. If they had trached her would the DRG have changed?
-Jane
The nursing admission assessment dated xx/xx/xx notes an alteration in skin integrity documented in the wound/skin assessment.
Based on your clinical judgement can you provide a diagnosis for the skin alteration? (e.g. Decubitus/pressure ulcer, vascular ulcer, lesion, excoriation, unspecified or other more appropriate diagnosis).
We also ask if it was Present on Admission
We list the site, the nursing description including -redness or open, stage if documented, wound bed, surrounding tissue, any treatment such as pressure ulcer prevention protocol order or a dressing etc.
You could certainly add skin tear to the reasonable clinical options.
Don't know if this is what you were looking for? My understanding is only the physician make the diagnosis and determine Present on Admission Status. The wound can be staged by the wound care nurse.
"Charlie"
Charrington Nicholl Morell
WFL Div CDI Mgr
Tampa, FL
pam
Pamela Parris,RN
Clinical Documentation Integrity
MUSC
Charleston, South Carolina 29425
Pager: 12295
(843) 792-3442
MAIN HOSPITAL
Confidentiality Notice: If you have received this communication in error, please notify the sender immediately. The documents accompanying this facsimile/electronic transmission contain confidential information intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure. If the reader of this message is not the intended recipient, or an employee responsible for delivering the message to the intended recipient, you are hereby notified that any disclosure, dissemination, distribution, or copying of this communication is strictly prohibited.
Your principal diagnosis is going to be a pregnancy complication code. However, if patient was trached then yes depending on procedures she had she would group to a DRG 003 or 004. Without a trach, she would still group to a pregnancy DRG.
Dorie