cpccoder2008
True Blue
A patient came in with Coffee-ground emesis, an EGD was performed and stated that no active bleeding was seen nor was any old blood seen as well. It was stated they patient did however have Esophagitis. On the discharge summary they have as number one Coffee-ground emesis secondary to esophagitis. Number two was acute blood loss anemia due to the GI bleed. I choose the GI bleed as principle and our auditor is stating that it must be changed to Esophagitis which I believe that is incorrect, if anything it should be changed to Acute Blood Loss Anemia. This is the discharge summary.
HOSPITAL COURSE: The patient was admitted. It was felt that we should treat his active gastrointestinal bleed as his hemoglobin was 5.9 from a baseline of 11. The patient was placed on a Protonix drip and GI was consulted. The patient was transfused 2 units of packed red blood cells. His hemoglobin improved mildly overnight but only to 8.8, so another one unit was given. He underwent an EGD on January 6, 2013, which showed a severe LA class D esophagitis involving the mid to distal esophagus with no active bleeding or blood seen. The patient was transitioned to a b.i.d. PPI therapy and should have a repeat upper endoscopy in 2 months to further assess. Initially, the patient was doing well and swallowing, but this deteriorated and he was unable to swallow on the day of discharge. I spoke extensively with the family who felt that the patient would for sure never wanted feeding tube, which he had communicated prior to getting very ill. I discussed aspiration risk and the family felt it was worthwhile to let him eat and see if he could slightly recover. He also initially was admitted in acute renal failure. This improved with IV fluid hydration. His other medical problems were stable. He was continued on his home medications. He was transported to his normal Radiation/Oncology appointment on the day of discharge and brought back afterwards. I also gave him 1 unit of packed red blood cells on the day of discharge as the patient is chronically ill and his hemoglobin was around 9. I felt that hemoglobin of 10 was a good goal for him. There was no longer any active bleed
Thanks
HOSPITAL COURSE: The patient was admitted. It was felt that we should treat his active gastrointestinal bleed as his hemoglobin was 5.9 from a baseline of 11. The patient was placed on a Protonix drip and GI was consulted. The patient was transfused 2 units of packed red blood cells. His hemoglobin improved mildly overnight but only to 8.8, so another one unit was given. He underwent an EGD on January 6, 2013, which showed a severe LA class D esophagitis involving the mid to distal esophagus with no active bleeding or blood seen. The patient was transitioned to a b.i.d. PPI therapy and should have a repeat upper endoscopy in 2 months to further assess. Initially, the patient was doing well and swallowing, but this deteriorated and he was unable to swallow on the day of discharge. I spoke extensively with the family who felt that the patient would for sure never wanted feeding tube, which he had communicated prior to getting very ill. I discussed aspiration risk and the family felt it was worthwhile to let him eat and see if he could slightly recover. He also initially was admitted in acute renal failure. This improved with IV fluid hydration. His other medical problems were stable. He was continued on his home medications. He was transported to his normal Radiation/Oncology appointment on the day of discharge and brought back afterwards. I also gave him 1 unit of packed red blood cells on the day of discharge as the patient is chronically ill and his hemoglobin was around 9. I felt that hemoglobin of 10 was a good goal for him. There was no longer any active bleed
Thanks