26 year old Type 1 diabetic female admitted with nonhealing ulcer, persistent fevers and x-rays revealing osteomyelitis of the great toe not responsive to 4 weeks of antibiotics. Underwent amputation of great toe and debridement of metatarsal head. Hemoglobin postoperatively was 8.7. She was transfused 2 units packed red blood cells.
My thoughts, is that the patient may have some manifestations of the DM, the acuity level of the osteomyelitis should be queried, and pt was given PRBC's for a low Hbg. The Low BP could be due to blood loss so a query should be initiated. kittycat
At our hospital since we have to have a diagnosis for any treatment/procedure, we would have to ask for a diagnosis for the treatment of 2 units of PRBC's. Since the osteomyelitis is a manifestation of the Diabetes, it is assumed as an automatic link, which would code to diabetes with other manifestations. I also, would really watch for signs of sepsis since the patient had persistent fevers.
Diabetes associated with (PVD) peripheral circulatory.
2. I could ask if the osteomyelitis was acute or chronic.
3. I would also want to know if the osteomyelitis was associated with or due to the type I DM.
4. I could ask for a diagnosis/reason for the transfusion.
I would ask if the osteomyelitis was a manifestation/associated with of the Type I DM.
I would ask if the osteomyelitis was acute or chronic.
I would ask for a diagnosis/reason for the blood transfusion.
Some very interesting questions and even more interesting solutions on how to ask them.
As it stands, although it is faulty logic, there is a default that drives the relationship between osteomyelitis and diabetes UNLESS the physician specifically states that the link is inappropriate in the case. Certainly, in a diabetic foot ulcer, the relationship to the underlying osteomyelitis is a "gimme." But it is presumptuous to assume that a NON-diabetic skin ulcer has anything to do at all with diabetes as a complication of the disease. In our case, unlike the three examples provided in Coding Clinic, we are NOT given the information that the ulcer was a diabetic one, so we MUST establish a relationship between the disease of diabetes, the ulcer and the subsequent osteomyelitis as many suggested above.
As we have no history of how long the ulcer was present nor if the diagnosis of osteo or symptoms of its being there had been made before the four weeks of antibiotics, it is quite reasonable to seek clarification regarding the acuity.
Regarding the hemoglobin level post-op and the transfusion, maye it would be worthwhile to discover what the hemoglobin level was pre-up! Ya think? In this case, it was 8.4 pre-operatively. Kat - I don't see where the BP was low. Annie - don't ask for "blood loss anemia" when there is no indication of blood loss. Gotta do your homework first. Between the pre-op Hb being the same as post-op, the operation of removal of a toe associated with minimal bleeding (check the anesthesia note - it gives estimated blood loss - if there were 50 cc of blood lost, how could there possibly be anemia from that?) To ask for a "reason for the transfusion," the doc will answer "the hemoglobin was low." That won't get you there.
Anyhow, taking a look at the whole clinical picture, from the evidence we have, the most likely source of the hemoglobin having been at that level is anemia due to chronic inifection. But, as this is a Type 1 diabetic, we should also look at the creatinines to see if it might be due to chronic kidney disease (see if the GFR is under 45), as well. Or in a 26 year old female, it could be from menstrual bleeding. So the best we can do is ask if there is a specific diagnosis that can explain the hemoglobin levels that low, that required transfusion, and please provide the record with the cause of that low hemoglobin (and maybe give the doc a few choices, including selecting several of them).
Good thinking, all.
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