Wiki Coding Question

[alana.thew@yahoo.com]

What would be the correct code for this situation?
Patient with ESRD on Dialysis, enters ER in evening with some signs of blood clotting around dialysis catheter. Patient states she went to dialysis that morning and the dialysis tech was distracted and it was discovered that he had forgotten to give the patient heparin during dialysis. The ER treats patient by cleaning dialysis catheter and flushed with heparin. What is the correct diagnosis code for this situation?

 

[OpenClaims]

Assuming the patient does not have ESRD associated with Diabetes or Hypertension AND assuming that you're only wanting diagnosis and not any CPT's;

ESRD (N18.6)
Dependence on Renal Dialysis (Z99.2)

 

[thomas7331]

What would be the correct code for this situation?
Patient with ESRD on Dialysis, enters ER in evening with some signs of blood clotting around dialysis catheter. Patient states she went to dialysis that morning and the dialysis tech was distracted and it was discovered that he had forgotten to give the patient heparin during dialysis. The ER treats patient by cleaning dialysis catheter and flushed with heparin. What is the correct diagnosis code for this situation?

I disagree with the response above - the patient did not present to the ER for treatment of their ESRD, so that would not be an appropriate code assignment. This scenario sounds more like a complication of dialysis.

But what you're describing sounds like a history - there isn't enough information here to properly assign a code. In order to assign a diagnosis code, you need a provider's assessment of the patient. What did the physician document as a diagnosis for the patient in this case? If this is all the provider documented, I would return it back for an addendum to get the provider's final diagnosis for the encounter.

 

[OpenClaims]

I disagree with the response above - the patient did not present to the ER for treatment of their ESRD, so that would not be an appropriate code assignment. This scenario sounds more like a complication of dialysis.

But what you're describing sounds like a history - there isn't enough information here to properly assign a code. In order to assign a diagnosis code, you need a provider's assessment of the patient. What did the physician document as a diagnosis for the patient in this case? If this is all the provider documented, I would return it back for an addendum to get the provider's final diagnosis for the encounter.

This is true, if you're coding ER, then the complications would come first. Author - make sure the provider documented as so.