Getting Down to the Nitty-Gritty with RAC, QIO,

Getting Down to the Nitty-Gritty with RAC, QIO,

Getting Down to the Nitty-Gritty with RAC, QIO, and Other Denials Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS Independent Consultant Same Language? Gap? Clinical Patient Care Documentation = Code(s) Any communication barriers? Economic Coding Reimbursement ???????? Full Circle Process

Use a comprehensive communication process from front to back and vise versa Include all other key areas Wrap any retrospective activities including audit results into the CDI program for a full circle approach CD Co I di ng Documentation

RE A C Pt Back to Basics Define the Issue(s) and the Fit(s) Is it a documentation issue or is it coding? Is this a clinical closeness question? Is this a surgery where it is what it is? Is this a high-risk or high- change topic? How does it fit with the clinical picture of the patient? Coding Topics

Coagulopathy in a patient on Coumadin Asystole Suprapubic catheter Pathology validation Procedures Verify Documentation Label / Name Acuity Supportive Validation Severity

Condition / DX Significance Connection Contradiction The Due To, LINK, and Name It The #1 Driver = The Principal Diagnosis The principal diagnosis (PDx) is the initial driver to the (one) MDC Then driving on to the most specific DRG/MS-DRG With of course several factors Selection of the inpatient admission PDx: Defined: in the UHDDS as "that

condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. involved and according to the guidelines (several) Circumstances of admission always govern the selection of the PDx. Source: ICD-9-CM Official Guidelines for Coding and Reporting, Section II Meet the definition of the PDx. Also, diagnostic work up and/or therapy provided weighs in MS-DRG Flow Renal Failure Insufficiency, failure, or

AKI? Standard definitions RIFLE criteria Others Severity driver (CC or MCC) Various clinical presentations Acute, chronic, or acute on chronic Asymptomatic Several etiologies Coding Guidelines What Is Acute Kidney Injury? Acute kidney injury A common clinical syndrome defined as a sudden onset of reduced kidney function manifested by increased serum creatinine or a reduction in

urine output It is NOT the underlying renal pathology Currently a preferred term and synonym for acute renal failure or acute kidney failure Some physicians may not agree Acute kidney insufficiency The same definition as acute kidney injury, yet the rise of creatinine or fall of urine output fails to meet the acute kidney injury criteria Azotemia A medical condition characterized by abnormally

high levels of nitrogencontaining compounds, such as urea (BUN), creatinine, various body waste compounds, and other nitrogen-rich compounds in the blood Uremia Resource: Srisawat, N.; Hoste, E.; Kellum, J.A. Modern Classification of Acute Kidney Injury. Blood Purification 2010;29:300307. A term used to loosely describe Available for free at: 13 the illness accompanying kidney failure, in particular the nitrogenous waste products associated with the failure of this organ

Acute Kidney Injury Diagnostic criteria for acute kidney injury An abrupt (within 48 hours) reduction in kidney function currently defined as an absolute increase in serum creatinine of more than or equal to 0.3 mg/dl ( 26.4 mol/l), a percentage increase in serum mol/l), a percentage increase in serum creatinine of more than or equal to 50% (1.5-fold from baseline), or a reduction in urine output (documented oliguria of less than 0.5 ml/kg per hour for more than six hours). The above criteria include both an absolute and a percentage change in creatinine to accommodate variations related to age, gender, and body mass index and to reduce the need for a baseline creatinine but do require at least two creatinine values within 48 hours. The urine output criterion was included based on the predictive importance of this measure but with the awareness that urine outputs may not be measured routinely in nonintensive care unit settings. It is assumed that the diagnosis based on the urine output criterion alone will require exclusion of urinary tract obstructions that reduce urine output or of other easily reversible causes of reduced urine output. The above criteria should be used in the context of the clinical presentation and following adequate fluid resuscitation when applicable. Note: Many acute kidney diseases exist, and some (but not all) of them may result in acute kidney injury (AKI). Because diagnostic criteria are not documented, some cases of AKI may not be diagnosed. Furthermore, AKI may be superimposed on or lead to chronic kidney disease.

*Source: Mehta et al. Critical Care 2007 11:R31 doi:10.1186/cc5713 Acute Renal Failure 2 Dx Denials Issue: Remove the secondary diagnosis code 584.9 for acute renal failure as not supported in the documentation. Example #1: This patient presented to have her pacemaker replaced and was found to be dehydrated, so she was placed on IV fluids Initially, the diagnosis of pre-renal azotemia was documented in the H&P and by the cardiology consultant; however, the diagnosis of "acute renal failure" on IV fluid, improving - was documented by the hospitalist the next following days as seen in the progress notes Labs: BUN elevated 58, 52, and 51 with a normal value of 718 Creatinine also elevated at 1.5 and 1.4 with a normal value of 0.61.3 The progress note on discharge documents an improvement with

the BUN - 36 and creatinine of 1.2; however, the DS does NOT mention acute renal failure Acute Renal Failure 2 Dx Denials Issue: Remove the secondary diagnosis code 584.9 for acute renal failure as not supported in the documentation. Example #2: This patient had no documentation of her "baseline, so the reviewer's impression of an increase of 50% of her baseline was assumed upon her creatinine level on admission. "Acute renal failure resolved was documented on the DS; however, acute renal insufficiency was documented throughout the progress notes On admission, the BUN was (normal) at 18 and creatinine was (elevated) at 1.5 Normal values for BUN = 823 and CR = 0.41.0

The BUN increased from 18 to 24 and the creatinine also increased from 1.5 to 1.7 IV fluids 1/2 NSS 80 cc/hr for 24 hours were ordered on the day of admission I&Os were monitored and "last shift was 720/800" as noted on the progress note Patient was transferred from telemetry to ICU on day #2 with a change in mental status Diagnosis Status Differential diagnosis Ruled-out vs. ruled-in Rule-out, possible, probable When documented? (Discharge documentation) Resolved Natural progression - acute, chronic, acute on chronic, acute vs. chronic, etc.

Carried through the chart Does it make sense? Slightly Low and No Treatment Issue: The diagnosis of hyponatremia, code 276.1, was suggested to be deleted stating that since the values were "slightly low and no treatment was done, this secondary diagnosis does not meet the UHDDS definition for an appropriate secondary diagnosis to code. Rebuttal: The diagnosis of hyponatremia was consistently documented throughout the chart by the provider in the discharge summary, H&P, and multiple progress notes. The lab values do support the diagnosis of hyponatremia with the normal value range being 133 145 and this patient's values being 132, 127, 128, and 130. One Note Standing Issue: Delete the secondary diagnosis code 410.71, subendocardial infarction.

Reasoning: The MI code was suggested to delete per the UHDDS definition of reporting other secondary diagnoses as there was only one progress note stating "?non ST elev MI, but the subsequent cardiology notes do not support a ruling-in of MI nor does the discharge summary confirm the MI. Troponins were increased: 0.1, 1.7, 2.4 (on the 22nd), then 1.1 on the 25th (normal - 0.00.5) 5-day stay from the 22nd 27th "?MI" was documented. The coding guidelines state with a rule-out/ possible, etc. diagnosis, it has to be documented in the discharge documentation. Since this ?MI was only documented in the 23rd (day #1) progress notes and nowhere else, this would have been a query opportunity. Malnutrition Values Commonly Used to Grade the Severity of Protein-Energy Malnutrition Measurement

Normal Mild Malnutrition Moderate Malnutrition Severe Malnutrition Normal weight (%) 90110 8590 7585 < 75 Body mass index 1924* 1818.9

1617.9 < 16 Serum albumin (g/dL) 3.55.0 3.13.4 2.43.0 < 2.4 Serum transferrin (mg/dL) 220400 201219 150200

< 150 Total lymphocyte count (per mm3) 20003500 15011999 8001500 < 800 Delayed hypersensitivity index 2 2 1

0 *In the elderly, BMI < 21 may increase mortality risk. Delayed hypersensitivity index quantitates the amount of induration elicited by skin testing using a common antigen, such as those derived from Candida sp or Trichophyton sp. Induration grade 0 = < 0.5 cm, 1 = 0.50.9 cm, 2 = 1.0 cm. Source: Kwashiorkor Code 260 Malnutrition (calorie) 263.9 Degree

First 263.1 Second 263.0 Third 262 Mild (protein) 263.1 Moderate (protein) 263.0 Severe 261 Protein-calorie 262 Malignant 260 Mild (protein) 263.1 Moderate (protein) 263.0 Protein 260 Protein-calorie 263.9 Mild 263.1 Moderate 263.0 Severe 262 Specified type NEC 263.8

Severe 261 Protein-calorie NEC 262 MCC: 260, 261, 262 CC: 263.2, 263.8, 263.9 CC 3Q9009, page 6: Code 260, Kwashiorkor, is not appropriate since the provider did not specifically document this condition. Kwashiorkor syndrome is a condition that is caused by severe protein deficiency that is usually seen in some underdeveloped areas in Africa and Central America; however it is extremely rare in the US. The National Center for Health Statistics (NCHS) is considering a

proposal to revise the index entries under mid and moderate protein malnutrition in order to provide a clearer direction to the coder. Malnutrition Change Examples Case #1 Issue: Change the secondary code 260 (MCC) severe Kwashiorkor to 263.9 (CC) unspecified malnutrition. Agree that "severe" was not documented, only "protein calorie malnutrition. The patient appears to be thin, not being able to get his protein-enriched drinks or supplements due to monetary funds being short.

Case # 2 Issue: Change from 262 severe malnutrition (MCC) to 263.9 malnutrition NOS (CC). This patient has multiple myeloma, not on any treatment, amyloidosis thought to be secondary to the myeloma, UTI, intractable vomiting likely is secondary to gastroparesis, which is secondary to the multiple myeloma, hypokalemia, etc. BMI-16, on TPN, which was increased to 40 cc/hour, "malnourishment" was documented, but did not see the degree of malnutrition and/or "severe"

documented. The DS notes she does have marked "cachexia and malnutrition. The labs showed her albumin at 3.3 on the date of admission (normal range 3.55.0). Why Is the Patient Here? Issue: Change the PDx from cirrhosis, liver, NOS 571.8 to hepatic encephalopathy 572.2. This patient has a history of chronic liver disease and cirrhosis, has had previous problems with hepatic encephalopathy, supposed to be on sorbitol at home and refused to take Lactulose in the past and/or has been intermittently noncompliant with taking this medication, now admitted to the ICU for one day with increasing confusion, disorientation, and an ammonia level of 239. She has been out of town and probably missed her dose of Sorbitol for a number of days. Documentation through the chart supports the hepatic encephalopathy with MS-DRG change from 432 to 442.

Why Is the Patient Here? Issue: The PDx code was changed from end-stage liver disease secondary to alcohol abuse 571.2 to hepatic encephalopathy 572.2. Rebuttal: The focus on this case was the end-stage liver disease, not the encephalopathy. Coding Clinic 1Q2002, page 3, was referenced to use hepatic encephalopathy as the life-threatening event that requires immediate treatment be listed first; however, this reference was applied out of context. He was directly admitted to the hospital due to recent confusion, abdominal pain and swelling, also complaining that he is diffusely weak, with joint pains and anorexia. He has possible encephalopathy, treated with Lactulose; ascites treated with Lasix; jaundice, and UTI treated with Levaquin. Also, he was noted to have liver masses with ascites with a biopsy that was inconclusive, laryngeal mass, and refuses hospice. When History of Is Documented Issue: The secondary diagnosis code was suggested to be

changed from an active cancer to a history of cancer. Change from 189.0 to V10.52. Rebuttal: We respectively disagree with the change because even though the patient had a nephrectomy, she is still on current treatment. Per the H&P: "She has metastatic renal cell carcinoma on Sutent therapy status post nephrectomy. She follows up with Dr. R at General Hospital. Her last appointment at General Hospital was missed as she was in the hospital. She will continue Sutent. She also has decreased white blood cells secondary to chemotherapy - the patient will follow up with hematology/oncology. (Included a copy of the drug index for Sutent, an antineoplastic agent, in the rebuttal) Respiratory Failure Denial Example Issue: Re-sequence the PDx from acute respiratory failure 518.81 to AECOPD 491.21 based on the fact that the patient is a smoker and the ABGs and the pulseox do not reflect this diagnosis.

Rebuttal: The physician clearly documents respiratory failure through the chart and as the reason for admission. The discharge summary (DS) provides the final diagnosis of "respiratory failure due to AECB. Hypercapnic respiratory failure was documented by the physician on 03/28 in the progress notes. He was significantly dyspneic and with a frequent cough that substantially interferes with his ability to even communicate ... with an assessment of "respiratory failure due to acute exacerbation of COPD. The ABGs were taken while the patient was receiving O2 via nasal cannula. The interdisciplinary progress note on 03/27 at 5-6 am documents the patient's respirations as "rapid and shallow, R=38 labored, SPO2 - 84-86%, 2 L O2". He was admitted to the ICU, given IV antibiotics, corticosteroids, aerosol bronchodilators, and oxygen.

Labs: CO2 serum on 03/27 at 1330 was elevated at 29.5 with a normal range of 23 29. See the ABGs, day of admission at 1331 as listed: FiO2 - 27.00, pH - 7.392, elevated PCO2 50.8, PO2 - 91.4, O2 sat - 97.2, BEvt elevated at 4.3 and HCO3 elevated at 30.2. The interpretation was "compensated respiratory acidemia. Pneumonia Issue: A notification from RAC stating the documentation in the medical record does not support the assignment of pneumonia as a secondary diagnosis code 486. Rebuttal: Refer to the transcribed reports, radiology reports, and progress notes on pages xxx. This patient has an extensive DVT of the right lower extremity with an IVC filter placed. She also has metastatic cancer and atrial fib, which is controlled. She is not a candidate for Coumadin due to her frail condition and high risk for falls. (T=99, HR=68, RR=16, BP=156/148) She had a dry cough on admission, WBC noted to be 21,000, and infiltrate was noted on the CT chest. The diagnosis of pneumonia was documented in the discharge summary and the progress note on the 8th day through the day before discharge. She was given Levaquin IV 500 mg on the 6th, 7th, and the 8th. The day of

discharge, the 9th, "pneumonia, change to oral Levaquin" was documented. The secondary diagnosis of pneumonia was coded appropriately, documented by the physician, and treated with Levaquin IV; therefore, this diagnosis code should remain as originally billed. 2nd Review for the Unrelated Dx-Px Principal diagnosis change from acute respiratory failure 518.81 to bradycardia 427.89. This case is a good example of review of chain of events, pdx definition, and rereview of the 981 MS-DRG. This 72 y/o male with history of CAD was admitted with severe bradycardia. He was admitted to ICU with skin being cold and clammy, heart rate 45, then dropping to 40, respiratory rate about 18% with 97% saturations on 40% BIPAP, BP was about 90/37, blood gas showing hypoxemia, with chest x-ray showing interstitial pulmonary edema with peribronchial scarring, and was bradycardic, idioventricular rhythm, with

a LBBB on the EKG. ER record shows the patient presented light-headed, dizzy, passed out, and low heart rate. His respirations regular and unlabored, (P-29-regular, R-18-unlabored), airway clear, breath sounds clear bilaterally to auscultation, A&O x3 on arrival, O2 sat 100% RA. His heart rate was 110 after Epi and complained of chest pain, then given Morphine and Zofran. Noted on the ER disposition, the patient was admitted to SICU, IV infusing, continuous oxygen administration with O2 sat of 93 on 15L O2 delivered by NRB. Per the H&P, he received Atrophine without significant response. Following Epinephrine, he developed tachycardia with increase in shortness of breath and mild diaphoresis. IV Lasix was given. After arrival to SICU, he became significantly hypotensive and Dopamine was started. His Coumadin was reversed and permanent pacemaker was scheduled for the morning. Surgeries To Check Further

Just a few suggestions Transbronchial lung biopsy Pleurodesis Adhesions Excisional debridement Mechanical vent 96 hours Pleurodesis Pleurodesis Mechanical Code: 34.6 MS-DRG: Surgical Major chest procedures 163 165 RW = 1.7758 5.0828 Chemical Code 34.92 With cancer chemotherapy substance

34.92 (99.25) Tetracycline 34.92 (99.21) MS-DRG: Medical from the PDx Coding Clinic reference 4Q2007, 1Q2007, 1Q1992, 2Q1989, May-June 1985 Mechanical: Look for: Scraping, abrasion, or (partial) pleurectomy Chemical language Injection Instillation

Examples: Sterile pack in 100cc NS into pleural space 4 grams of talc were infused per protocol through the chest tube 2 air slice and talcum Bleomycin, Doxycycline, etc. 30 Pleurodesis Chemical Pleurodesis A 24 French chest tube was placed over trocar into position, where I subsequently instilled 200 ML of pleurodesing solution consisting of Doxycycline, D50, and sterile talc. The patient was then moved in several positions by moving the

bed to allow for dispersion then the chest tube was connected to Pleurovac suction, left to water seal at this time. The patient tolerated the procedure quite well ... Both Mechanical and Chemical Pleurodesis "Mechanical and talc pleurodesis" was done. "I then made an incision in the posterior aspect of the 5th intercostal space and placed an 11 mm trocar. I then scraped the parietal pleura with a Bovie scratch to do the mechanical pleurodesis. This was done through both ports. ..." (Most other notes in the chart refer to only "talc" - but the OP provides the most detail)

31 Lung Biopsy Biopsy lung NEC 33.27 Brush 33.24 Closed (percutaneous, needle) 33.26 Brush 33.24 Endoscopic 33.27 Brush 33.24 Endoscopic 33.27 Brush 33.24 Open 33.28 Thorascopic 33.20 Transbronchial 33.27

Transthoracic 33.26 Notes as of Oct. 1, 2010 33.24 Revised inclusion term for transbronchoscopic needle aspiration of bronchus (TBNA) New excludes note for Minibronchoalveolar lavage (miniBAL) is classified to 33.29 other diagnostic procedures on lung and bronchus 33.27 New inclusion term for transbronchoscopic needle aspiration of lung (TBNA) 33.29 New excludes note that

bronchoalveolar lavage is classified to code 33.24 Lung Biopsy MS-DRGs Medical MS-DRGs Brush 33.24 Closed / Percutaneous / needle 33.26 Fine needle aspiration (FNA) of lung Transthoracic 33.26 Transthoracic needle biopsy of lung (TTNB) Code 33.26 Excludes: endoscopic biopsy of lung (33.27) thoracoscopic lung biopsy (33.20)

Surgical MS-DRGs 163165: Major chest procedures Open - 33.28 Transbronchial - 33.27 166168: Other resp system OR procedures Thoracoscopic 33.20 Closed (NEC) - 33.27 Closed endoscopic - 33.27 Transbronchial Lung Biopsy Documentation must specify the scope passed thru the bronchus and into the lung and actual lung tissue was obtained. AHA Coding Clinic 2Q2009

3Q2004 3Q1991 The transbronchial biopsy procedure is performed using a tiny forceps passed through a channel of the bronchoscope into the lung. The forceps puncture the terminal bronchus, and samples of the peribronchial alveoli (lung tissue) are taken (4Q1992, pages 2728). Transbronchial Lung Biopsy The original codes submitted included both procedure codes for the closed endoscopic biopsy of the bronchus 33.24 and the lung 33.27, where the lung biopsy code was deleted as not supported in the documentation. Procedure: Fiberscopic bronchoscopy with transbronchial biopsies and bronchoalveolar lavage for lung mass with hemoptysis. Endobronchial

biopsies as well as transbronchial biopsy following fluoroscopy guidance. Five biopsies were taken. Specimen - bronchial lavage to be sent to microbiology and cytology and lung biopsies to be sent to pathology. The pathology reports note specimens from both the bronchus and lung. The references noted in the results letter were also pertinent; however, in Coding Clinic 2Q2009, page 16, this instruction also includes the following statement: Code 33.27 (closed endoscopic biopsy of lung) is specific for transbronchoscopic lung biopsy, and the inclusion terms mention the use of fluoroscopic guidance or control and that would reflect the increased resources needed for the procedure. Transbronchial Lung Biopsy Issue: Both the bronchoscopy with biopsy codes 33.24 (bronchus) and 33.27 - transbronchial (lung) biopsy were coded and the lung bx code 33.27 was deleted. The OR report states " endobronchial brushings were obtained from the right lower lobe, followed by transbronchial biopsies and bronchoalveolar lavage." The path does not show any lung tissue.

MS-DRG change from 166 to 186. Adhesions When are adhesions significant enough to code additionally - both the diagnosis and the procedure? When Do You Code Adhesions? When obstruction is present or adhesions are cause of pain or dysfunction and lysis is major procedure Obstruction not present Strong band of adhesions prevents surgeon from access to the organ being removed Requires lysis before operation can proceed Significance must be documented by surgeon Source: Coding Clinic 4th Q 1990 Query for Adhesions? Delete the peritoneal adhesions codes: lysis of adhesions procedure code 54.51 and the secondary diagnosis - 568.0 Codes: Dx: 540.9, 568.0; Px: 47.01 and 54.51 MS-DRG change from to 337 - peritoneal adhesiolysis, rw 1.4789 to 343 appendectomy 0.9568

(0.5221 difference) Reasoning: Since the "minor adhesions" which were easily lysed was part of the principal procedure, both codes would be inappropriate. OR procedure: Laparoscopic appendectomy and laparoscopic lysis of adhesions Description: The patient had "numerous omental adhesions in the midline from previous laparotomy, which were bluntly taken down There were again some adhesions down to the lower abdomen and pelvis The remainder of the abdominal exam was otherwise unremarkable other than multiple omental adhesions and other aspects did not impact on the planned procedure. Other documentation: discharge summary - no documentation, postop note - did include lysis of adhesions Vent and Hours Issue: Time of 96 hour threshold 96.72 = > 96 hours 96.71 = < 96 hours

Order to intubate on 12/26 at 1320 Nursing notes report patient intubated by anesthesia at 1330 Order to discharge on 12/30 at 1120 Progress note on 12/30 document: "Pt extubated by RT at 1230. (Pt placed on 50% venti mask.) Excisional Debridement Excisional debridements Description of the wound(s) Depth and definitions Procedure explained Instruments, methods, etc. Location of the procedure OR Bedside

Wound care Patients clinical picture Current Past and relevant Excisional Debridement Denial Example 1 Chronic multiple ulcerations. Using a #10 blade, necrotic tissue was EXCISED from the left and right ulcerations, partial thickness level. Very large ulceration to the left medial ankle area, measuring approx 11.4 cm x 6.5 cm, depth of 0.5 cm, mostly granulated tissue, foul odor, with one maggot found the right is pale looking, with minimal granulation, measuring approx 2.5 cm x 2.4 cm, with a depth of 0.3. Excisional Debridement Denial Example 2 Venous stasis ulcer left lower leg with pseudomonas, cellulitis of the left leg, diabetic foot ulcer, etc. This ulcer has not been

healing for about 1 month. A bedside debridement was done and that took most of the dead tissue out. The cellulitis has pretty much subsided. There is quite a bit of induration about the stasis ulcer, about 5 cm in diameter with a central cavity with necrotic tissue and some granulation tissue. ... with forceps and a knife to debride the wound and remove some necrotic tissue, particularly in the central portion. A #10 blade knife and some forceps were used to debride some of the necrotic tissue around the edges of the wound and also the central portion of the wound. After this tissue was adequately removed, there was some small amount of bleeding which was good and there was some granulation tissue that was cleaned up and necrotic tissue removed so granulation tissue could improve the wound Excisional Debridement Denial Example 3 The debridement procedure code 86.22 excisional was changed to 86.28 non-excisional, based on lack of supporting documentation. This patient had an infected left foot with an incision and debridement. Documentation includes: Attention was then directed to the plantar

aspect of the left foot under the left second MPJ where an open lesion with gray, fibrous necrotic tissue was noted and malodorous, measuring approximately 1.7 cm. A linear longitudinal incision was performed down to the midsagittal plane of the ulceration from the base of the second toe down to the midfoot area. Incision deepened utilizing sharp and blunt technique. At this time, the major neurovascular bundles were identified and gently retracted from surgical site. At this time, a large volume of grayish necrotic to blackish tissue was noted down the midportion of the ulceration all the way down but not entering into the bone and the tendon. This was completely debrided utilizing sharp and blunt technique. Cultures were taken throughout this. The bone was probed at and appeared to be white and healthy. (It was then followed by a Pulsavac with three liters to flush the foot.) Multiple Debridements What Level(s)? Issue: There were x 3 debridement sites, with different type of debridement levels performed. This patient has multiple (x 3) decubitus ulcers: sacrum - stage 4 with eschar necrosis, right lateral hip - stage 3, and the right shoulder, stage 3 - all with eschar and necrosis.

DS - He underwent full-thickness to fascia debridement over the sacrum about 7 cm with some undermining noted. Eschar removed. Infection noted the lateral right hip was 3x5 cm and had a yellowish eschar (debrided) along with the right shoulder ulcer measuring 2x4 cm debrided with good granulation tissue underneath. OR rpt: All 3 wounds debrided with sharp scalpel DISSECTION. 2 of the wounds were fully debrided down to a fairly good granulation of tissue" and the sacral ulcer was full thickness to fascia over the sacrum, about 7 cm, some area of undermining noted ... was all sharply debrided in a similar manner. Multiple Ulcers and Multiple Depths Multiple sacral & buttock ulcers, stage 3 and 4, infected The DS states: the patient underwent EXCISION of the ulcerS by Dr. C documents a good description of the decubitus the skin over the gluteal region is bluish, multiple ulcer and serosanguineous discharge, entire right gluteal region is covered by a decubitus, left gluteal region - medial half is covered by decubitus skin ulcers

and discharge ... The OR report documents: the ulcer was completely excised down TO the sacrum. A small piece of the sacrum was removed. Debridement: Excisional or Not? Issue: Debridement code changed 86.22 (excisional) to 86.28 (non-excisional). Patient #1: Progress note documentation included: debridement of the hyperkeratotic skin and wound eschar using a tweezers/scalpel/scissors. the sharp debridement of the yellow slough film that is overlying in the wound base, NOTE: does not describe "excisional, more like scraping/

cleaning Patient #2: The patient is diabetic with right lower extremity cellulitis, redness around wound area, and 100% covered with black hard eschar. She was on Rocephin IV to start, then switched to Zosyn . Progress notes document: Tx-Received wound dressing and sharp debridement, 100% removal of black eschar, etc. Day # 1 post-debridement. This 1x1.5 cm with eschar reddened area 4x4 inches approx - not as "angry" as yesterday, Queries Balancing Act Risk versus opportunity Supportive documentation and coding Solid

No gaps Describe the patient, treatment, decision-making Evidence-based Tie up all loose ends Accuracy is what counts! Everything Deserves a Closer Look Maximization - NO Optimization - NO Solid - YES Consistent - YES Supported - YES In Closing Audience Questions Thank you for attending Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS [email protected]

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