rule-out sepsis work-up

Sepsis. Diagnosis is sepsis due to pneumonia. The diagnoses are presented in this way: Sepsis due to pneumonia UTI due to E. Coli Now, if you code the sepsis, it will be sepsis unspecified because you do not have an organism documented for the pneumonia or the sepsis (they don't know)038.9, 99591 and 486. If you go to code the UTI with E. Coli, there is an edit that excludes 041.4 with 038.9. Do you put it in, or do you just leave the organism for the UTI ...

Patient was bolused with multiple normal saline boluses along with s/l hespan with eventual need for vasopressin agent to include Levophed. ...

Because of the concern of the marked leukocytosis and the (s/l presumption) of sepsis due to that ...

Has anyone ever heard of the verbiage "follow Mom's rule" in ER plan of care?? Physician states, "he is to follow Mom's rule"....... ...

Hello. It might just be too early but can someone tell me the rule as to when to add A? Like the doc says HISTORY: 72-year-old woman who..... Should I be adding A to the beginning? HISTORY: A 72-year-old... ...

In the diagnosis section this doc says "SIRS. Rule out s/l PTI." So, I found SIRS (systemic inflammatory response syndrome) but I can't find out what s/l PTI is to go along with it. Any ideas? ...

What is BOS ruling on using the word "post" when typing (for example) status postcholecystectomy? Where in BOS is this found? ...

murmurs, gallops, or rubs OR murmurs, gallops or rubs? I am old school and taught that the first is correct, but I waste a huge amount of time and keystrokes correcting this and other instances like this. I looked at the AAMT link, but really didn't get a sufficient answer if the second is OK to leave as that is the preferred way ASR puts it; however, every grammar site I looked at online puts the additional comma in. ...

As American-born, English-speaking doctors are becoming the minority, I think all companies should openly state what percentage of ESL will be encountered in a new job and then ask 1 year of experience for each percentage of ESL; e.g. 40% ESL (the maximum I can personally tolerate) 4 years experience plus a differential in the line rate, too. What do y'all think? ...

dictated: levothyroxine 1200 micrograms daily transcribed: levothyroxine 1200 mcg daily is this correct? pls help. ...

EMS responding to a patient who just had ablation for SVT last week and is complaining of weakness and dizziness. Cannot find with much searching. Thanks for your help! ...

This was published in the Federal Register last week, correct? I have a friend who is in a battle with an insurance company over a very sick child. They are always throwing up obstacles for coverage. She told me that out-of-network treatment is covered at 50% of 200% of Medicare rates. So we are trying to uncover exactly what that rate is. Is the CMS Final Rule document what I am looking for to help her? Is Coder here? Expert insight would be so appreciated ...

When you get NJA you have the 3 options as we did before. When you choose to "make up time", at the very end of the explaination, it says something along the line of entering a leave request on teamwork for excused no pay? This only makes sense if in fact you cannot or do not make up the time, but the policy does not explain it that way. Example: You work 2 hours and get NJA. You have 6 hours to make up and can only make up 4. The remaining 2 hours must be en ...

I really don't see what it matters now that we don't get PTO and if we aren't getting paid for it so what. Seems stupid to me that they would care how much time we have off if they aren't paying us anyway but anyone know now the most days you can take for the year part time and full time? I know they took away PTO for part timers and cut it for full time but wasn't sure of the new rules. Also, when does it start over again if you used up your unpaid time off days. ...

no patient name is given? Do we transcribe it as "UNKNOWN, NAME" or "NO NAME, GIVEN" etc? Or where this info is located? I've searched DQS guidelines and TSG and can't seem to find it. TIA! ...

Do I need to put a marker in there as a warning. I totally forgot and never usually get this..checking the guides now coming up empty ...

-- can you treat it. Certainly, you can't get paid for doing anything with it. So, study up, doc. ...

I know the 2nd edition says no comma between 5 feet 5 inches, for example. Does anyone have the current BOS edition and knows if this is still the same? ...

apostrophes? eg. ADLs or ADL's I gather that the move to make hard-measured units (rather than eyeballed measuired -- such as: a 5-mm screw versus a 5 mm laceration -- died years ago. Is this correct? I'm anticipating doing some testing for a new position and don't want to fail this sort of "basics" Thanks! ...

I just had a report sent back by a doc where she had corrected every superotemporal and inferotemporal to supra- and infra-. I was actually going by what my spell-checker was telling me. Is either of these never used? Is there a rule for usage? Thanks in advance! ...

I've had a clinic in WA state refuse to release to me or my new PCP some archived files I had sent to them from my doctor in San Francisco. A local hospital MR department said that the files are mine since I paid for them and that they absolutely should have told me why they were refusing to release these particular files--I was just repeatedly refused. I was told that there is a HIPAA clause that permits re-release of such documents, but I'm having trouble finding t ...

it sounds like UTE disease, what is this? Thank you. ...

Does anyone know the BOS rule for drug names that are technically all caps, i.e., TUMS, GRALISE? Do they stay all caps or is it okay to capitalize just the first letter, or is it company/client preference? QA is telling me just to capitalize the first letter so as not to draw more attention than needed to the drug name in the report, but I can't document this in the Book of Style. Thanks in advance! ...

that are sent to QA, the ones you are forced to send due to the client wanting all reports QA's, a certain dictator, etc....I was just reading in the "Rewards" Plan that these reports are NOT counted towards our QA submission . I have read posts here where MTs were frustrated because they thought they WERE. Please read (I think page 10 but not sure) where it says they are NOT. If you feel yours are counting against you, copy and paste the paragraph and send it to your CCM. ...

I'm just curious as I'm seeing it constantly now. For decades, I have always been trained and told never to start a sentence with a number and to spell it out or add something like the work A or The like: The 20-year-old patient... instead of: 20-year-old patient... I've been correcting it, but since I'm seeing it all the time, I'm wondering if this rule isn't followed anymore and, if this rule is still in place, they need to start training these ...

This is an ER Note for guy with alcohol poisoning. last heading of the dictation, dr states what s/l solving this. Never seen as heading, cannot find anything near. solviness? Would think the heading would be impression or something similar... ...

rule-out sepsis work-up - Anja

hyphens - dsauverwald

no hyphen for rule out, workup or work-up--per - your client NM

rule-out-sepsis workup - MTtoday

wow - dsauverwald

We'll just agree to disagree...absolutely need the hyphens for easier read and clarity. - MTtoday

I agree - looks funny, but correct in this particular context. - vnolan

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