Clinical coding secrets (16)

Clinical coding secrets (16)

By Dr.Sedeek El Hakeem (MBBS, TQM, cert.CII, IFCE)

Today I’ll present a new dose of Clinical coding secrets, I have been

abstracted them from my reading Australian Coding Standards and practicing Australian clinical coding(ICD10AM,ACHI) at a private general hospital (150 beds) in KSA

Long Term/Nursing Home Type Inpatients

Due to the lack of nursing home and other types of support services in some areas, patients may be admitted to hospitals as long term residents or nursing home type patients. These admissions may arise as a direct admission from home (or elsewhere) without the need for acute care, or as an episode type change where the patient is no longer receiving acute care. (Refer to the Health Data Standards Committee (2006), National Health Data Dictionary, Version 13, AIHW for definitions of 'Care type' and 'Acute care'.)

In such cases, a code from the category Z75 Problems related to medical facilities and other health care should be assigned as the principal diagnosis. Any conditions which subsequently arise during this episode of care, should be coded as additional diagnoses (according to ACS 0002 Additional diagnoses).

When patients are admitted for treatment of an acute problem and then remain in hospital as a long term resident or nursing home type patient, and the episode care type is not changed, then the acute condition should be coded as the principal diagnosis and a Z75.- code assigned as an additional diagnosis.

Today I have been presented a new dose of Clinical coding secrets; I hope this dose will help you to sail safely in the sea of clinical coding as you know coding translates medical service into money 
Next time I’ll provide a new dose of Clinical coding secrets

For more information contact me on
 @dr8q
sedeeks2011@gmail.com
0582128676



الكتب الأكثر مبيعا

الكتب الأكثر مبيعا
https://www.facebook.com/groups/1565789396978362/

Clinical coding secrets (13

Clinical coding secrets (13)

By Dr.Sedeek El Hakeem (MBBS, TQM, cert.CII, IFCE)

Today I’ll present a new dose of Clinical coding secrets, I have been abstracted them from my reading Australian Coding Standards and practicing Australian clinical coding(ICD10AM,ACHI) at a private general hospital (150 beds) in KSA

Sequelae of Injuries, Poisoning, Toxic Effects and Other External Causes

             Definition

A 'sequela' of an injury is a current condition that was caused by a previously occurring injury, poisoning, toxic effect or other external cause.

EXAMPLE 1:

Oesophageal stricture due to previous ingestion of hydrochloric acid.

             Classification

There is no time limit as to when a sequela code can be used. The residual condition may be apparent immediately following the acute phase, such as loose bodies in a joint due to a previous fracture, or it may occur months or years later, such as scarring due to previous tendon laceration.

A sequela of injury, poisoning, toxic effect or other external cause may be documented in one of the following ways:

•      late (effect of)

•      old

•      sequela of

•      due to previous injury, poisoning, toxic effect or other external cause that occurred in a previous episode of care

•      following a previous injury, poisoning, toxic effect or other external cause that occurred in a previous episode of care

As the underlying cause is no longer current, a code for an acute injury, poisoning, toxic effect or other external cause is not assigned.

EXAMPLE 2:

An admission for tendon repair following laceration of tendon of finger two weeks ago is not a sequela as the laceration is still present and being treated.

The coding of sequelae of injury, poisoning, toxic effects or other external causes requires three codes:

•      the residual condition or nature of the sequela (current condition)

•      the cause of the sequela (the previous condition)

•      the external cause of the injury, poisoning, toxic effect, etc

The residual condition or nature of the sequela is sequenced first, followed by the cause of the late effect.

EXAMPLE 3:

Malunion following fracture of radius caused by fall from ladder at home while painting house.

Codes:           M84.03        Malunion of fracture, forearm

                       T92.1           Sequelae of fracture of forearm and upper arm

                       Y86              Sequelae of other accidents

An appropriate place of occurrence code (Y92.-)

The sequelae diagnosis codes for injury are:

T90.-       Sequelae of injuries of head

T91.-       Sequelae of injuries of neck and trunk

T92.-       Sequelae of injuries of upper limb

T93.-       Sequelae of injuries of lower limb

T94.-       Sequelae of injuries involving multiple and unspecified body regions

T95.-       Sequelae of burns and frostbite

T96          Sequelae of poisonings by drugs, medicaments and biological substances

T97          Sequelae of toxic effects of substances chiefly nonmedical as to source

T98.-       Sequelae of other and unspecified effects of external causes

The external cause sequelae codes are:

Y85.-       Sequelae of transport accidents

Y86         Sequelae of other accidents

Y87.-       Sequelae of intentional self-harm, assault and events of undetermined intent

Y88.-       Sequelae with surgical and medical care as external cause

Y89.-       Sequelae of other external causes

Further treatment of an injury (eg removal of an orthopaedic pin) is not to be regarded as a sequela of the original injury. These cases should be assigned to the appropriate Z code describing the need for further treatment (eg Z47.0 Follow-up care involving removal of fracture plate and other internal fixation device) with the appropriate procedure code.

Today I have been presented a new dose of Clinical coding secrets; I hope this dose will help you to sail safely in the sea of clinical coding as you know coding translates medical service into money 

Next time I’ll provide a new dose of Clinical coding secrets

For more information contact me on

 @dr8q

sedeeks2011@gmail.com

0582128676

Clinical coding secrets (12)

Clinical coding secrets (12)

By Dr.Sedeek El Hakeem (MBBS, TQM, cert.CII, IFCE)

Today I’ll present a new dose of Clinical coding secrets, I have been abstracted them from my reading Australian Coding Standards and practicing Australian clinical coding(ICD10AM,ACHI) at a private general hospital (150 beds) in KSA
HYPERTENSION
When coding combinations of hypertension, heart and kidney disorders, it is important to distinguish if, and how, they are related.


HYPERTENSION
• Hypertension may cause heart and/or kidney disease.
• Hypertension may be caused by other conditions, including some kidney disorders.
• Hypertension and heart and kidney disease may be unrelated although they are present at the same time.
==HYPERTENSIVE HEART DISEASE (I11)
Certain heart conditions: 

I50.- Heart failure 
I51.4 Myocarditis, unspecified 
I51.5 Myocardial degeneration 
I51.6 Cardiovascular disease, unspecified 
I51.7 Cardiomegaly
I51.8 Other ill-defined heart diseases 
I51.9 Heart disease, unspecified 

are classified to category I11 Hypertensive heart disease when a causal relationship is stated (eg 'due to hypertension' or 'hypertensive'). In such cases, assign only a code from category I11.

The same heart conditions with hypertension, but without a stated causal relationship, are coded separately. Sequence according to the circumstances of the episode of care.
== HYPERTENSIVE HEART AND KIDNEY DISEASE (I13)
Assign codes from combination category I13 Hypertensive heart and kidney disease, when both hypertensive heart disease (I11) and hypertensive kidney disease (I12) are present. The term 'hypertensive' by default indicates that there is a causal relationship.

(See also ACS 1438 Chronic kidney disease).
== SECONDARY HYPERTENSION (I15)
Assign these codes when hypertension is stated to be 'due to' or 'secondary to' another condition, such as renal artery stenosis (I15.0 Renovascular hypertension) or phaeochromocytoma (I15.2 Hypertension secondary to endocrine disorders).

Assign also a code from N18.- Chronic kidney disease where I15.0 Renovascular hypertension or I15.1 Hypertension secondary to other kidney disorders are assigned (see also ACS 1438 Chronic kidney disease).

Today I presented a new dose of Clinical coding secrets; I hope this dose will help you to sail safely in the sea of clinical coding as you know coding translates medical service into money 
Next time I’ll provide a new dose of Clinical coding secrets

For more information contact me on
 @dr8q
sedeeks2011@gmail.com
0582128676

الشيخ محمد حصان = العنكبوت - ذكرى الشيخ ابراهيم سلام بالمسجد الاحمدى 1982 م

الشيخ محمد حصان = العنكبوت - ذكرى الشيخ ابراهيم سلام بالمسجد الاحمدى 1982 م

What is Diagnostic Related Groups (DRGs)?

What is Medical or Clinical Coding ?

Clinical coding secrets 1

Clinical coding secrets(part1)

by Dr Sedeek El Hakeem

These clinical coding standards have been written with the basic objective of satisfying sound coding convention according to ICD-10-AM and ACHI. Consideration of the various uses of inpatient data collections was secondary. Issues such as DRG allocation, research and planning aims were considered only after the requirement for accurate ICD-10-AM and ACHI coding was satisfied.

The clinical record should be the primary source for the coding of inpatient morbidity data. Accurate coding is possible only after access to consistent and complete clinical information. Without good documentation, coding guidelines are difficult, if not impossible, to apply. It is assumed that coding decisions are not made solely based on information provided on the clinical record front sheet (or a copy of same) but that analysis of the entire clinical record is performed before code assignment.

The responsibility for recording accurate diagnoses and procedures, in particular principal diagnosis, lies with the clinician, not the clinical coder.

The 'ICD' was first used to classify causes of mortality as recorded at the registration of death. Later, its scope was extended to include diagnoses in morbidity. It is important to note that although the ICD is primarily designed for the classification of diseases and injuries with a formal diagnosis, not every problem or reason for coming into contact with health services can be categorised in this way. Consequently, the ICD provides for a wide variety of signs, symptoms, abnormal findings, complaints and social circumstances that may stand in place of a diagnosis.

Next time I'll provide more Clinical coding secrets

for more details kindly visit the site 

Rabaa is a Humanitarian Tragedy HD | رابعة .. قصة الإنسانية

هل أصبح العرب ألعوبة الغرب؟

هل أصبح العرب ألعوبة الغرب؟

بقلم صديق الحكيم

 هذا العنوان القاسي تجرأت عليه بعدما قرأت معلومات منتشرة (لم يتم التأكد من مدي صحتها ) عن زعيم داعش الذي تعيث مليشياته في الأرض فسادا علي مساحات شاسعة من بلاد العرب

وهناك كم كبير من الأسئلة عن هذا التوسع الهائل في مناطق نفوذ داعش وهذا الظهور المفاجئ وهذا التمويل الكبير وهذا التنسيق مع دول غربية وإقليمية لبيع النقط المسروق من سوريا والعراق

وأسئلة أخري كثيرة بقيت بلا أجوبة واضحة أو مقنعة حتي قرأت المعلومات التالية رغم عدم التأكد من مدي صدقيتها إلا أنها تمثل تفسيرا لما يجري وهي مثل المثل السائر لا يوجد دخان من غير نار

تناقلت مواقع التواصل الاجتماعي موضوعا مهما تضمن تمكن الجانب الايراني من كشف الهوية الحقيقة لزعيم الدولة الاسلامية (داعش) .
حيث بين الموضوع أن الاسم الحقيقي لابو بكر البغدادي هو "شمعون ايلوت" من اب وام يهوديان .
حيث أن المدعو "ايلوت" قد تم تجنيده في الموساد الاسرائيلية لمدة عام واحد خاض خلالها العديد من التجارب والاختبارات الفكرية والميدانية ليكون مؤهلاً لقيادة فكر مدمر للمجتمعات العربية والاسلامية.
هذا وفي تسريبات قيل انها منسوبة لادوار سنودن، ونشرتها صحف ومواقع اخبارية، ان زعيم تنظيم "الدولة الاسلامية" ابو بكر البغدادي تعاون مع أجهزة مخابرات اميركية وبريطانية وإسرائيلية لخلق تنظيم إرهابي قادر على استقطاب المتطرفين من جميع أنحاء العالم في مكان واحد.

ولو صحت هذه التسريبات فهذا يعني ضمن ما يعني

أن العرب أضحوا ألعوبة للغرب دون مواربة أو ميكياج الأمر أصبح ظاهر للعيان بوجه القبيح

وأعتقد أن هذه هي طبيعة المرحلة الحالية من تدشين الشرق الأوسط الجديد فأمريكا مثلا رغم ما تتعرض له غزة من دمار وقتل ومذابح لا تري إلا حليفتها إسرائيل وتنحاز إليها دون مواربة ودون خشية من العرب أو حتي مراعاة لمشاعرهم أو غضبهم طبعا بعيدا عن الأنسانية والرحمة بالأنسان

والخلاصة

أصبح اللعب علي المكشوب وانتقل العرب من مرحلة عرائس المارونيت التي تحرك من خلف ستار إلي مرحلة الشطرنج أي أصبح العرب حجارة علي رقعة الشطرنج تحركها يد الغرب

ويبقي الشعر معبرا عن حالنا مع الشاعر الرائع محمود غنيم

إني تذكرت والذكرى مؤرقةٌ = مجدًا تليدًا بأيدينا أضعناه

ويْح العروبة كان الكون مسرحها = فأصبحت تتوارى في زواياه

أنَّى اتجهت إلى الإسلام في بلدٍ = تجده كالطير مقصوصًا جناحاه

كم صرّفتنا يدٌ كنا نُصرّفها = وبات يحكمنا شعب ملكناه

2 أغسطس 2014