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Principes of Inpatient Coding*
Are you getting calls from coders, case managers, or prompts in the chart?
This article will provide you with valuable insight into the documentation requirements for accurate inpatient coding, help in decreasing time-consuming requests for clarifications and denial appeals, and see its ties into health care fiscal integrity and quality of patient care. |
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Septicemia*
A 73 year old male presents to the Emergency Room with complaints of fever to 103°, malaise, and lethargy. On arrival at the ER, his blood pressure was low (BP 60/palpable). The patient was hydrated appropriately to increase intravascular perfusion. He went into shock and was resuscitated, intubated, and attached to a mechanical ventilator. Workup showed increased WBC to 12,000, but blood culture and sensitivity studies failed to disclose any organisms in the blood. The physicians attending to this patient documented all over his medical record the diagnoses, "septicemia," "septic shock," and "sepsis." He was placed on intravenous antibiotics, and after the third day his fever resolved. He was discharged on the sixth hospital day. The principal diagnosis was coded to 786.59, septic shock. This case grouped to DRG 416. Was this case coded and billed appropriately? Or, could this be construed as a case of fraud and abuse? |
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