AHA Coding Clinic® for ICD-9 - 2012 Issue 3; Ask the Editor
Mechanical Ventilation for Airway Protection
The patient presented to the Emergency Department (ED) in full cardiac arrest and respiratory failure due to an acute myocardial infarction. He was resuscitated, transtracheally intubated and placed on mechanical ventilation. The patient was admitted to the intensive care unit and after a short period he expired. The ED physician documented acute respiratory failure. However, the attending physician did not document acute respiratory failure in the health record. Is acute respiratory failure a codeable secondary diagnosis based on the ED physician’s documentation of this condition? ...
Subscribe or sign in to view the full article.
Article Overview
This article discusses a documentation scenario involving emergency department and attending physician records, mechanical ventilation, and whether a respiratory failure diagnosis can be reported as a secondary diagnosis. It is aimed at coding professionals, CDI staff, and clinical documentation reviewers who need to understand how provider documentation affects diagnosis assignment in acute care records. The guidance focuses on reconciling documentation across clinicians and when provider query may be appropriate.
Why This Topic Matters
Accurate diagnosis assignment depends on which provider documented the condition and whether the record contains conflicting information. This topic is important for compliant inpatient and emergency department coding review.
What You Will Learn
- How provider documentation from different clinicians affects diagnosis review
- How a mechanical ventilation case in the emergency and ICU setting may raise coding questions
- When documentation inconsistency may require provider query
- How secondary diagnosis consideration is discussed in an acute care record context
Who Should Read This
- Medical coders
- CDI specialists
- Health information management professionals
- Auditors
- Clinical documentation reviewers
Codes Discussed
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com