Health Information Management

Q&A: Atelectasis query for secondary diagnosis

CDI Strategies, September 25, 2014

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Q: When atelectasis is noted on an ancillary test such as a CT-scan of the abdomen or chest x-ray, can nursing documentation of turning, coughing, and deep breathing be considered an intervention that qualifies as one of the criteria to meet a secondary diagnosis?
 
A: In order to answer your question more information surrounding the circumstances of the encounter  is required. Atelectasis is usually considered an integral condition when it occurs following surgery because the turning, coughing, and deep breathing is typically routine protocol for this type of patient.
 
There are specific guidelines for coding conditions that may be an integral part of a disease process. If the condition is routinely associated with the disease process or procedure and no additional monitoring or treatment is ordered to evaluate the condition, then the additional code would not be separately assigned. If the attending provider orders additional monitoring or treatment to evaluate the condition, such as continued x-rays to monitor the progress and resolution of the atelectasis, it would be a reportable condition. Some other examples of integral conditions would be an “ileus” following bowel surgery, or “pleural effusions” in a patient with congestive heart failure that is not aggressively treated.
 
Before we assign a code for a secondary diagnoses, we need to ask ourselves, does it meet UHDDS criteria for a secondary diagnoses? The CDI specialist needs to determine if the condition required:
  • Clinical evaluation
  • Therapeutic treatment or a diagnostic procedures
  • An extended length of stay
  • Increased nursing care and/or monitoring
  • Support from least one clinical indicator
Additionally, consider whether:
  • Other providers would arrive at the same conclusion/make the same diagnosis
  • The diagnosis is integral to another condition
  • This diagnosis relates to this episode of care
  • The diagnosis was documented by a treating provider
  • There is a conflict with the attending provider
Since abnormal findings (laboratory, x-ray, pathology, and other diagnostic results) are not coded and reported unless the attending provider indicates their clinical significanceyou first need to ensure the finding is a reportable diagnosis before you can query for the associated diagnosis. If findings are outside the normal range and the attending has ordered other tests to evaluate the condition or prescribed treatment, it would be appropriate to query the physician to have the clinical significance clarified and diagnosis added.
 
Editor’s Note: CDI Boot Camp Instructor Sharme Brodie RN, CCDS, answered this question. Contact her at sbrodie@blr.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview. This article originally published on the ACDIS Blog.



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