Coding, Classification & Reimbursement

Orders

  • 1.  Orders

    Posted 07-10-2018 13:51
    I have a question about the clarification of a surgery order.
    The surgeon is stating that the electronic order "Consent for EGD with FB removal" is an order for surgery. I know that I can assume that since they are ordering an EGD consent that the patient is having surgery but can that really be classified as a procedure order? Also, can you use documentation in the H&P as a surgery order? In the assessment and plan, they state that they will proceed with EGD. The surgeon is also questioning this as an order as well.

    Any thoughts would be greatly appreciated!​

    ------------------------------
    Amber Clouse, RHIT
    Health Information Department Manager
    Pratt Regional Medical Center
    ------------------------------


  • 2.  RE: Orders

    Posted 07-11-2018 18:56
    Amber,

    We require that all surgeries begin with "ADMIT TO OUTPATIENT SURGERY" and then the surgery to be performed.

    We have a problem with our physicians, for example, ordering only the type and cross and a given number of units of PRBC from the blood bank.  The order is incomplete because they're missing the "TRANSFUSE X UNITS" order that actually sets the action in motion.


    ------------------------------
    Jesse Floyd, RHIA
    ------------------------------



  • 3.  RE: Orders

    Posted 07-12-2018 12:06
    In this situation, they were already admitted and then decided to do a diagnostic EGD. Otherwise, that is also what we do too.

    ---------------------------------
    Amber Clouse, RHIT
    Health Information Department Manager
    Pratt Regional Medical Center
    ---------------------------------





  • 4.  RE: Orders

    Posted 08-09-2018 12:51
    ​Does anyone else have any ideas?

    ------------------------------
    Amber Clouse, RHIT
    Health Information Department Manager
    Pratt Regional Medical Center
    ------------------------------



  • 5.  RE: Orders

    Posted 12-19-2018 01:02
    Amber,

    It'd be the same thing.  The patient is admitted, for example, as an observation.  There's the admission order "Admit patient to Observation Status..."

    Then there's an order transferring them to the OR for the EGD.  Following surgery, there's an order transferring them to PACU/Recovery, and then they're discharged from the OR back to the floor.

    The order to obtain a consent for the EGD isn't good enough, just as an order to do a cross and match isn't sufficient to actually transfuse blood.


    ------------------------------
    Jesse Floyd, RHIA
    ------------------------------