intubated prior to sedation....

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
We have a patient that was transferred from an outside hospital after a MVC. He was intubated prior to transfer so that they could sedate him and reduce his hip fx. He was sedated on arrival but we extubated within hours of his arrival. Resp failure is documented and is the only MCC at this point.

Would you code this dx considering that he was intubated for airway protection required for sedation?

Thanks!

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

Comments

  • sharon.colesharon.cole
    edited May 2016
    I wouldn't since it was only for airway protection.

    Sharon Cole, RN, CCDS
    CDI Specialist Team Leader
    Providence Health Center
    254.751.4256
    Sharon.cole@phn-waco.org
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    That’s my feeling too. I think it would be a denial target....

    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
  • sharon.colesharon.cole
    edited May 2016
    Yes, I don't think the resp fail would meet criteria as a valid diagnosis anyway. We never code it when they were intubated for sedation, airway protection, no gag, or because behavior is out of control (danger to self or others).

    Sharon Cole, RN, CCDS
    CDI Specialist Team Leader
    Providence Health Center
    254.751.4256
    Sharon.cole@phn-waco.org
  • angelisa.romanelloangelisa.romanello
    edited May 2016
    I would like to ask....the patient was intubated to be sedated to have his hip fracture reduced.....was this need for intubation a resource necessary for the plan of care? I am just curious since the closed reduction may not have been accomplished if the patient was not sedated.
    Thank you
    Lisa

    Lisa Romanello,RN,BSN,FNS,CCDS
    Manager, Clinical Documentation Improvement Specialist
    CJW Medical Center
    Quality and Compliance
    804-228-6527
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