I have had several people ask me how I keep the excitement alive in my department which has been in existence 8 years. It is not hard to do when Documentation Improvement is my love, passion and life. I continually look for areas of improvement and where we can go from where we are today. I am never satisfied with accomplishing only the basics... but push forward to reach for the stars. I firmly believe that Documentation Improvement is one of the most important departments in the ...
We have been using the MDC 25 Human Immunodeficiency Virus Infections listing of AIDS related diagnoses as a guideline to determine when the diagnosis of AIDS may be coded as opposed to the V08 code which indicates HIV positivity but having never experienced an AIDS related illness. Some of the diagnoses, especially under DRG 977, seem vague to say the least. Examples are volume depletion/dehydration, unspecified anemia, unspecified thrombocytopenia, and blindness and low vision. Other diagnoses ...
Dr. Gold, I believe if an inpatient claim is not coded right, the claim can be denied due to medical necessity. An example would be of a patient that is admitted as an inpatient with O2 sats in the lower 60's. The Milliman criteria the UR case manager used was for respiratory failure. The physician admit order documents "obstructive sleep apnea and hypoxemia." The coder codes 327.23 obstructive sleep apnea as a principal diagnosis. I would propose a query for respiratory failure due to ...
This is a common question we receive from CDI Specialists in pediatric hospitals: Our PICU doctors are documenting "acute respiratory failure" or "post op respiratory failure" on our congenital heart anomaly repairs. The patients are coming back from surgery sedated and on the ventilator. It doesn't appear that they truly are in "acute respiratory failure." They're sedated post op due to the complexity of the surgery. How should I address this with the ...
I recently handed out the Physician Documentation Improvement Pocket Guides to my docs and my Pediatricians asked if there was specific criteria for SIRS in the pediatric population. Temp and increased WBC and the increase in bands probably stays the same, but the increase in HR >90 or RR>20 would obviously be different. What information can I give them. Is there a different pocket guide for pediatricians? And if not, what criteria changes are there for their documentation?
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