When to code a patient as post-op

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At the task meeting April 10,2014 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
  • for coding instructions for angiograms see Coronary Angiogram

Dr Garland feels that collectors judgement is best on when to include the surgery in the diagnosis.

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