When to code a patient as post-op: Difference between revisions

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From an email from May 2007:


'''Question: (from HSC data colelctors)'''
At the task meeting April 10,2012 we discussed the coding of post-op patients who come from other locations than the OR or PACU.
The question was:
"If a patient comes to medicine after having say a pace maker or some other surgical procedure how many days post-op do you put the procedure in your admit diagnosis"
When do we include the surgical procedure as part of our diagnosis?
*The decision was made that a specific time frame for including the surgery was not the best way.
*If the recent surgery is '''relevant''' to reason for admission then include it in your admit dx as the last code.
*For example a patient had a hip replacement 10 days ago,develops a HAP and is admitted to your unit.The surgery could go in the last diagnostic spot.
*If reason for admission to your ward has nothing to do with recent surgery they don't include it in your diagnosis/


'''Answer: (from an email from Trish)'''
= Special Instructions for Concordia Ortho patients ==
 
For Concordia MICU ONLY: If the patient was admitted from the Orthopedic ward and/or had any Orthopedic surgery/procedure during their current hospital admission (regardless of length of time of current admission and/or if moved between multiple centers during current admission); then do include the Orthopedic procedure in the admits (tag in the last admit diagnosis code slot). The reason is that the Concordia Directors are tracking the Orthopedic surgery patients that are being admitted to Concordia ICU. We specifically make sure everyone who has had an Orthopedic surgery during their current hospital stay; and then come to ICU for another reason, will have a tag in the last Admit Diagnosis slot indicating this Ortho surgery/procedure.  If the patient is admitted multiple times to the unit during a hospital stay then the same ortho procedure/surgery is included as the last admit diagnosis each time.
"If the recent surgery is relevant to reason for admission then include it in your admit dx as the last code.  
[[User:Mlaporte|Mlaporte]] 14:36, 2014 February 3 (CST)
 
If reason for admission to your ward has nothing to do with recent surgery they don't include.  
 
 
Within 3-4 days is good enough"






{{discussion}}
{{discussion}}
== Discussion ==
== Discussion
* If a date is to be used as a cut-off, it should be a distinct date rather than a range. Which should it be? [[User:Ttenbergen|Ttenbergen]] 16:39, 16 May 2008 (CDT)
 
* The statement to only include it if relevant doesn't seem to require a date at all. Should a date even be part of the guideline? [[User:Ttenbergen|Ttenbergen]] 16:39, 16 May 2008 (CDT)
 
**Does this include angiograms?  When a pt has an angiogram/plasty/stent just prior to(reason for admisssion) or during their admission to ICU, should the procedure(s) be included in their admit Dx upon transfer to Medicine? ...If the angio should be coded as an admit to Medicine does this apply only if angio done less than 4 days prior to transfer to ward?[[User:Mlaporte|Mlaporte]] 18:28, 21 December 2010 (CST)
*** At HSC it is our understanding that Angiogram/Plasty/Stent is treated as a test,If a pt comes into our ER and has an urgent angio prior to coming to the unit, we would put it in our last admit. When pt is on the unit and has an angio it would be my complication, and when we transfer the pt to another unit it would not be recoded. On my unit B3 because it is split into medicine/day surgery I will get day surgery pts that went for dx angio and come back as plasties and would have to be admitted for monitoring, they are admitted as medicine pts and their 1st admit would be the angio/plasty/stent and then what ever(most likely USA)--[[User:PStein|PStein]] 11:25, 22 December 2010 (CST)


**The following are the guidelines for coding Angiograms (as discussed with Trish):
**The following are the guidelines for coding Angiograms (as discussed with Trish):
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--When a patient admitted in an ICU goes for an angiogram and does not return to ICU; but, goes directly to a Medicine ward post-angio the Angiogram is a part of the Medicine Admit Diagnosis.[[User:Mlaporte|Mlaporte]] 18:24, 18 January 2011 (CST)
--When a patient admitted in an ICU goes for an angiogram and does not return to ICU; but, goes directly to a Medicine ward post-angio the Angiogram is a part of the Medicine Admit Diagnosis.[[User:Mlaporte|Mlaporte]] 18:24, 18 January 2011 (CST)
Is this about [[Registry Patient Type]] or about what? Ttenbergen 23:13, 2013 August 26 (CDT)
== Special Instructions for Concordia Ortho patients ==
For Concordia MICU ONLY: If the patient was admitted from the Orthopedic ward and/or had any Orthopedic surgery/procedure during their current hospital admission (regardless of length of time of current admission and/or if moved between multiple centers during current admission); then do include the Orthopedic procedure in the admits (tag in the last admit diagnosis code slot). The reason is that the Concordia Directors are tracking the Orthopedic surgery patients that are being admitted to Concordia ICU. We specifically make sure everyone who has had an Orthopedic surgery during their current hospital stay; and then come to ICU for another reason, will have a tag in the last Admit Diagnosis slot indicating this Ortho surgery/procedure.  If the patient is admitted multiple times to the unit during a hospital stay then the same ortho procedure/surgery is included as the last admit diagnosis each time.
[[User:Mlaporte|Mlaporte]] 14:36, 2014 February 3 (CST)
[[Category:Questions]]
[[Category:Diagnosis Coding]]
[[Category:Questions General Collection]]

Revision as of 08:21, 11 April 2014

At the task meeting April 10,2012 we discussed the coding of post-op patients who come from other locations than the OR or PACU. The question was: When do we include the surgical procedure as part of our diagnosis?

  • The decision was made that a specific time frame for including the surgery was not the best way.
  • If the recent surgery is relevant to reason for admission then include it in your admit dx as the last code.
  • For example a patient had a hip replacement 10 days ago,develops a HAP and is admitted to your unit.The surgery could go in the last diagnostic spot.
  • If reason for admission to your ward has nothing to do with recent surgery they don't include it in your diagnosis/

Special Instructions for Concordia Ortho patients =

For Concordia MICU ONLY: If the patient was admitted from the Orthopedic ward and/or had any Orthopedic surgery/procedure during their current hospital admission (regardless of length of time of current admission and/or if moved between multiple centers during current admission); then do include the Orthopedic procedure in the admits (tag in the last admit diagnosis code slot). The reason is that the Concordia Directors are tracking the Orthopedic surgery patients that are being admitted to Concordia ICU. We specifically make sure everyone who has had an Orthopedic surgery during their current hospital stay; and then come to ICU for another reason, will have a tag in the last Admit Diagnosis slot indicating this Ortho surgery/procedure. If the patient is admitted multiple times to the unit during a hospital stay then the same ortho procedure/surgery is included as the last admit diagnosis each time. Mlaporte 14:36, 2014 February 3 (CST)


Template:Discussion == Discussion

    • The following are the guidelines for coding Angiograms (as discussed with Trish):

-When a patient goes for an angiogram and is then admitted to ICU the Angiogram is part of the ICU Admit Diagnosis.

-When a patient admitted in an ICU goes for an angiogram and returns to the same ICU the Angiogram is an ICU Acquired Complication.

-When either of the above patients are transferred to the Medical ward DO NOT code the angiogram as part of the Medicine Admit Diagnosis. The data between continuous ICU and Medicine admissions can be linked; so there is no need to code the angiogram twice.

--When a patient admitted in an ICU goes for an angiogram and does not return to ICU; but, goes directly to a Medicine ward post-angio the Angiogram is a part of the Medicine Admit Diagnosis.Mlaporte 18:24, 18 January 2011 (CST)

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