Coding Questions

[mpete0719]

1) Inpatient Hospital Psychiatrist documents in the chart: Drug Withdrawal from Benzodiazepine. The patient is given Valium to ease any symptoms during the withdrawal process. I have been told by another medical professional that the doctor cannot document Drug Withdrawal if no signs or symptoms are present. The patient does not show any symptoms due to the Valium easing the withdrawal. Does anyone have any thoughts on this?

2) What is the criteria that a doctor would use to confirm a diagnosis of Severe Protein Calorie Malnutrition? Our facility criteria is: Low Protein <5.9 AND Low Albumin <3.3. We have been told that the Prealbumin must also be low in order to diagnose this condition.

Any help would be greatly appreciated!

[LTibbetts]

For the first one, use your inpatient coding guidelines to help you. If the patient was admitted for the withdrawl, there must have been a reason. They didn't just give the patient valium for no reason. Maybe the patient was vomiting, had a headache, or was anxious. For inpatient coding, you pick a primary code that supports the reason behind the admission (unless it was a sign or symptom of something else more definitive), and use that.

SELECTION OF PRINCIPAL DIAGNOSIS
The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care".In determining principal diagnosis the coding directives in the ICD-9-CM manuals, Volumes I, II, and III, take precedence over all other guidelines.

The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation the application of all coding guidelines is a difficult, if not impossible, task.