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MRA Thought of the Day – Think Before You Query

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Situation:

Lynn Salois, RHIT, CCS, CDIP, Director of Coding

Lynn Salois, RHIT, CCS, CDIP, Director of Coding

Take a moment to think about the physician queries you initiated or thought about initiating this week, specifically, those for abnormal lab results without a documented corresponding diagnosis. An example is a patient that underwent a colectomy; their pre-op HCT was 40 which decreased to 30 postoperatively. The patient was monitored without transfusion. Lab results are casually documented in the progress notes without a corresponding diagnosis.

Another example is a patient that underwent a vascular bypass; their pre-op HCT was 38 which decreased to 26 postoperatively. This patient was transfused one unit packed red blood cells and the results and treatment plan are documented in the progress notes without a documented corresponding diagnosis.

Question:

Is a query warranted in either of these scenarios?

Here are my thoughts…

  • Before seeking physician clarification of the abnormal lab results clinical significance, first determine whether such diagnosis would meet the definition of “other diagnoses” per coding guidelines. That being, clinical evaluation; or therapeutic treatment; or diagnostic procedures; or increased nursing care and/or monitoring; or extended length of stay.
  • In comparing both examples, the second example would warrant a query to seek clarification of a clinically significant diagnosis related to the abnormal HCT. The abnormal lab results were clinically evaluated above normal post-op monitoring and therapeutic treatment was received.

What are your thoughts?

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