Items Recommended to Coding Clinic

POA has been required in Florida since January 1, 2007. Some of the suggestions from their workgroup on coding issues are:

1. Fetal distress within 3 hours after admission should be exempt . Newborn is admitted when they are delivered. Signs and symptoms of these conditions may not appear or be clearly evident at the time the infant is delivered. This one specifically could become a litigation for hospitals, if it is perceived that this condition could have been prevented.

2. Complications of pregnancy/delivery codes with an antepartem condition with a delivery on this admission should be exempt . Example: Antepartum urinary tract infection with delivery on the current admission without postpartum complication, fifth-digit of "1".

3. Previous Myocardial Infarction (412) should be exempt . 412 = Hx of MI more than 8 weeks prior to admission.

4. Jaundice in newborns - needs more clarification What kinds of clinical documentation of signs or symptoms would need to be present at the time of admission to consider this condition present on admission.

5. Malnutrition - more clarification . What kinds of clinical documentation of signs or symptoms would need to be present at the time of admission to consider this condition present on admission.

6. Chemical /electrolyte imbalance - more clarification . What kinds of clinical documentation of signs or symptoms would need to be present at the time of admission to consider this condition present on admission.

7. Decubitus Ulcer - more clarification. If there is only a "wound care nurse note" in the record that indicates only "Stage I" at the time of admission, but then there is documentation of this becoming a "Stage III decubitus ulcer" was it present on admission? What kinds of clinical documentation of signs or symptoms would need to be present at the time of admission to consider this condition present on admission.