Health Information Management

Q&A: Obtaining documentation for multiple significant trauma

CDI Strategies, September 30, 2010

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Q: Whenever we get a trauma patient, it’s either very easy to get to the multiple significant trauma (MST) major diagnostic category (MDC), or it becomes a real challenge, especially taking into account the rules pertaining to two body sites.

For instance, in the case of an elderly patient who fell off his roof and had six rib fractures we spent a lot of time looking for other injuries to get us into the MST. Can you provide some additional discussion on this problem?
 
A: Many of the conditions classified as significant injuries often go undocumented. Examples include contusions of internal organs such as lung, liver, spleen, heart, brain, or injuries to internal organs. One example that illustrates this might be an injury to pelvic organs, bladder and urethra without mention of open wound into cavity (includes an injury to the urethra or bladder due to traumatic Foley catheter removal), combined with a closed fracture of the femur , which would group to MST, MS-DRG 965 without CC/MCC.   In this scenario the patient was admitted with the femur fracture but after admission accidentally pulled out his Foley catheter (balloon intact) causing trauma to the bladder/urethra. MST MS-DRGs do not require that both injuries be present on admission.
  
The second injury needed to get into MST can’t also do double duty as the CC or MCC; you need another MCC or CC to group to the higher-weighted DRG. Also be aware that many injuries may be considered hospital acquired conditions so make sure that the present-on-admission status is clearly documented for each injury identified.
 
Editor’s Note: Lynne Spryszak, RN, CCDS, CPC-A, answered this question. Spryszak is CDI education director at HCPro, Inc., in Marblehead MA. Her areas of expertise include clinical documentation and coding compliance, quality improvement, physician education, leadership, and program development. Contact her via e-mail at lspryszak@hcpro.com.



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