Admit Procedure: Difference between revisions

Line 41:

=== Directly related to the [[Admit Diagnosis]] ===

*These are procedures that didn't CAUSE the admission but are DIRECTLY related to one of the admit diagnoses

*The basic guidance for this is to include therapeutic procedures related to the admission diagnosis.

**e.g. Patient came to ED with bleeding esophageal varices and in ED got EGD with banding. Here the procedure did not cause the admission, but it was certainly related to the admission diagnosis

**e.g. Patient got an elective CABG for chronic ischemic heart disease/CAD -- the CABG is directly related to the CAD and so should be included as an admit procedure

**a more complicated example: Patient with cirrhosis with ascites is admitted with hepatorenal syndrome. While in ED the staff couldn't insert a Foley due to a urethral stricture, so urology came down to ED and did a cystoscopy to dilate the urethra and pass the Foley. Here admit diagnoses include: [[Hepatorenal syndrome]] and the [[Urethra, urethral stricture]], and in this case the cystoscopic dilation (coded by components with [[(T) Ureter, Bladder or Urethra]] and [[Dilation]]) is directly related to the stricture, in much the same way that the CABG is directly related to the CAD in the above example.

**a more complicated example: Patient with cirrhosis with ascites is admitted with hepatorenal syndrome. While in ED the staff couldn't insert a Foley due to a urethral stricture, so urology came down to ED and did a cystoscopy to dilate the urethra and pass the Foley. Here admit diagnoses include: [[Hepatorenal syndrome]] and the [[Urethra, urethral stricture]], and in this case the therapeutic cystoscopic dilation (coded by components with [[(T) Ureter, Bladder or Urethra]] and [[Dilation]]) is directly related to the stricture, in much the same way that the CABG is directly related to the CAD in the above example.

*Just as above ~~for~~ in the section on causally-related procedures, purely diagnostic procedures done prior to admission -- including procedures that merely demonstrated the presence of an admit diagnosis -- should not be coded as an admit procedure.

*Just as above in the section on causally-related procedures, purely diagnostic procedures done prior to admission -- including procedures that merely demonstrated the presence of an admit diagnosis -- should not be coded as an admit procedure.

**Indeed, the only diagnostic-only procedures that would be included as admit procedures are those that caused a complication that then required treatment --- e.g. a central line placement that led to a perforation -- and even here, this would then really come under the item above of

== Why within 48 hrs? ==

@@ Line 41: / Line 41: @@
 === Directly related to the [[Admit Diagnosis]] ===
 *These are procedures that didn't CAUSE the admission but are DIRECTLY related to one of the admit diagnoses
+*The basic guidance for this is to include therapeutic procedures related to the admission diagnosis.
 **e.g. Patient came to ED with bleeding esophageal varices and in ED got EGD with banding. Here the procedure did not cause the admission, but it was certainly related to the admission diagnosis
 **e.g. Patient got an elective CABG for chronic ischemic heart disease/CAD -- the CABG is directly related to the CAD and so should be included as an admit procedure
-**a more complicated example:  Patient with cirrhosis with ascites is admitted with hepatorenal syndrome.  While in ED the staff couldn't insert a Foley due to a urethral stricture, so urology came down to ED and did a cystoscopy to dilate the urethra and pass the Foley.  Here admit diagnoses include:  [[Hepatorenal syndrome]] and the [[Urethra, urethral stricture]], and in this case the cystoscopic dilation (coded by components with [[(T) Ureter, Bladder or Urethra]] and [[Dilation]]) is directly related to the stricture, in much the same way that the CABG is directly related to the CAD in the above example.
+**a more complicated example:  Patient with cirrhosis with ascites is admitted with hepatorenal syndrome.  While in ED the staff couldn't insert a Foley due to a urethral stricture, so urology came down to ED and did a cystoscopy to dilate the urethra and pass the Foley.  Here admit diagnoses include:  [[Hepatorenal syndrome]] and the [[Urethra, urethral stricture]], and in this case the therapeutic cystoscopic dilation (coded by components with [[(T) Ureter, Bladder or Urethra]] and [[Dilation]]) is directly related to the stricture, in much the same way that the CABG is directly related to the CAD in the above example.
-*Just as above for in the section on causally-related procedures, purely diagnostic procedures done prior to admission -- including procedures that merely demonstrated the presence of an admit diagnosis -- should not be coded as an admit procedure.
+*Just as above in the section on causally-related procedures, purely diagnostic procedures done prior to admission -- including procedures that merely demonstrated the presence of an admit diagnosis -- should not be coded as an admit procedure.
+**Indeed, the only diagnostic-only procedures that would be included as admit procedures are those that caused a complication that then required treatment --- e.g. a central line placement that led to a perforation -- and even here, this would then really come under the item above of
 == Why within 48 hrs? ==