A discharge summary reveals the patient’s principal diagnosis to be acute cerebrovascular accident with right sided upper and lower extremity weakness. This diagnostic statement presents two options for the coder: code the symptom as documented or discuss the record with the CDS to determine if a query is warranted for clarification of the weakness.
The coder recognizes right sided weakness as a clinical clue for hemiplegia and opts to discuss the record with the CDS. Both agree, to appropriately capture this patient’s severity of illness, a query is warranted. The result being a discharge summary addendum, further clarifying the right sided upper and lower extremity weakness as hemiplegia.
Here are my thoughts….
- If the coder chose to code the symptom, this would also have been a correct option; however, this would result in a missed opportunity to appropriately capture the severity of illness.
- Coding Clinic First Quarter 2010 directs the coder to report any neurological deficits caused by a CVA even when they have been resolved at the time of discharge from the hospital.
- Coders need to continue to utilize their detective skills in identifying documented clinical clues and discuss these clues with the CDS to determine if physician clarification is warranted.
What are your thoughts?