No. Coding should not be using a differential diagnosis. It depends on how it is worded. “Probable”, for example, will get coded. “Possible” will not. I have ED docs who will put everything but the kitchen sink into the differential because they think that will justify a higher level of billing. They frequently have a template with a huge list of differentials. And it does not meet criteria for source of infection.
> Greg Stanford, MD > Medical Director > Clinical Documentation Improvement and Outcomes > > 1840 Amherst Street | Winchester, Va 22601 > Phone: (540) 596 4999 Cell: 540 664 5736 | |[email protected] > <mailto:[email protected]> > > > > CONFIDENTIALITY NOTICE: This e-mail is confidential, may be legally > privileged, and for the intended recipient only. Access, disclosure, copying, > forwarding and distribution by any means is strictly prohibited. If received > in error, do not read but delete and e-mail confirmation to the sender. I would like to understand how my peers are abstracting a particular issue. I have a question for the group… If you have a patient in the EC and the physician lists as part of the differential diagnoses a UTI or PNA. Then the physician documents as his final EC diagnosis respiratory failure, COPD with exacerbation. Then let’s say the patient does have the clinical signs to support severe sepsis. (temp 102, Pulse 124, Respiratory failure documented and placed on vent). Do you count the differential diagnoses of UTI and PNA as a source of infection in this scenario? Thanks, Debra Debra M. Cox, BSN, RN STTI Member Corporate Quality Specialist | Quality Services 101 East Wood Street | Spartanburg, SC 29303 O: 864-560-2694 | c: 864-327-5731 | f: 864-560-7365 e: [email protected] <mailto:[email protected]>| w: SpartanburgRegional.com <http://www.spartanburgregional.com/> "You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete." ~R. Buckminster Fuller > > >
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