Question

5.15 Query format Subdomain V.D.2 Develop appropriate physician queries to resolve data and coding discrepancies Subdomain V.D.1 Implement provider querying techniques to resolve coding discrepancies Decide if the following is an acceptably-formatted physician query and defend your response. Dr. Hightower Mrs. Smith was admitted on 8/25, and two days later you mention in a progress note a stage three pressure ulcer of her heel that you debrided at the bedside. Can you clarify was the stage three heel pressure ulcer present on admission? Yes C. Coder 9/2 Ext. 2112 References AHIMA. 2013. Guidelines for achieving a compliant query process. Journal of AHIMA 84(2):50-53. AHIMA. 2008. Managing an effective query process. Journal of AHIMA 79 (10):83-88. Sharp, M. 2016. Secondary Data Sources. Chapter 7 in Health Information Management TechnologY A Applied Approach, 5th ed. Sayles, N. B. and L. Gordon, eds. Chicago: AHIMA.

Answer 1

Pressure ulcer as a pressure injury clinical coding and documentation improvement professional must have a goal to make sure the pressure ulcer with stages documented at the time of admission..It is called pressure Hospital acquired conditions (HACs) if this pressure ulcer not present on admission...It provide financial and quality of care consequences with different regulatory entities..clinical documentation should focus on deep tissue pressure injury whether it is unstageable,stage two or three..ICD-10-cm guidelines explain clearly for coding and reporting on admission..coding should indicate about pressure injury about when it happen whether on admission,out patient encounter,in ED, observation or outpatient surgery..If pressure ulcer present on Admission and it progress to the next stage it should be coded with two separate codes..one code for site and stage on admission and second code for the same ulcer site and which stage it progress during the stay..This pressure ulcer make more challenges for health care organization and for professional like if it is HAC like poor performance,quality and making more penalty financially..Pressure on Admission dilemma help query process physician for status of pressure ulcer,which can be unavoidable..If pressure ulcer mentioned in document after two days it should mention the  stage on the same site on pressure on admission..it is must we have to code the two stages as pressure on Admission..