Wake Up

  1. Where are the MDS nurses and LTC nursing questions. This site is going to sleep like our patients............. Tex
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  2. 21 Comments

  3. by   bandaidexpert
    I am here! I have a question for you, who completes section I, ICD-9 coding? I am having a horrible time with billing. The software we use defaults the codes over from billing to my MDS, and they are WRONG! I communicate with therapy to ensure the MDS, and 700 forms match. Then here comes billing with there UB-92 which does not match. Got any suggestions? I have discussed the issue with our computer guy and I kind of put him in the middle. I am very frustrated.

    dawn
  4. by   tex
    I put the ICD codes into the MDS. I don't do the billing, we have someone in adminstration that does that. When I see an ICD code put in at the time of the formal admission, I will review it, and notify that person to put the ICD code in. You just can't put in a generalized code in for cancer. I have not been called on that yet. I do submit the MDS's qw to the state. Tex P.S> thanks for waking the geriatics up
  5. by   Rustyhammer
    Usually it is Medical Records who puts in the ICD9's on admission,at least in our facility. I however update them when they come around again.
    -Russell
  6. by   KlareRN
    I am with you Tex- there is not much to read here anymore. In the facilities I go to- Medical Records do the ICD-9 codes. I have heard of the MDS co-ordinator doing them too. I guess whoever has the most time LOL!!!
  7. by   bandaidexpert
    tex, I also put ICD-9 codes on the MDS, but the UB-92, and 700 form from therapy have to match your MDS, how do you make sure this happens? If a resident is on a antihypertensive med, or an antidepressant med do you code in section I? I was always taught NOT to code in section I unless the dx affects ADL, cognitive, or death status. What do you do? To me, if a resident has a dx of HTN and is controlled by meds, it does not affect current status. Depression is a big issue in this regard. And a big flag on QI's. Thanks


    dawn
    most confused member
  8. by   tex
    You need to make sure that you have a dx for every medication the resident is taking. And of course, you better make sure that with Ambien, ativan (etc), zoloft (etc) and zyprexa (etc), if you don't have the dx by the time you are on your 14 day full PPS assessment, I either asked the nurses to get the dx, which most don't, or I call the MD's office. The don, puts out on the computor the list of medications w/the diagnosis, she knows if we don't have a dx, she faxes the MD, makes sure there is one. There is also an employee that goes through the inital paper signing w/the families or patient, she is suppose to have the ICD codes listed on a form that is placed in front of the paper in the chart, but of course that half of the time isn't done. I do not have the time to track and seek ICD codes, I use to do it in Home Care, so I know how to do it, I have my own ICD book. I have never worried about what the therapy dept's ICD codes are. I am married to an O.T. and they can use ICD codes that within nursing we don't use. If the major reason that a pt is admitted to your faciity for HTN, you better have another dx as the residents primary, that one doesn't float. As far as section, you need to be coding in this section. You are the nurse, who reads the h/p, you are providing the POC. On your QI report, we have stop putting a dx of depression (for example) if no s/s of and not on any medication. If they have depression w/psychosis or OBS etc with agitation etc then I don't mark on the list of dieases, I type in the ICD. It makes a difference on your reporting. Not being apart of section I is not the right way to go. Also in your regulation state manual, there is a list of acceptable dx for these particalur meds. When the resident has HTN, yes as well as other dx need to be marked if it could r/t to a possible problem during their recovery, increase their risk of falls or injury and functioning. Tex
  9. by   bandaidexpert
    Thanks tex.


    dawn
  10. by   jevans
    Reading your posts makes me realise how easy we have it in the UK

    Nurses do not code

    You all must have a mountain of paper work

    My sympathy goes out to each and everyone of you that needs to do it . It must be such a nightmare

    j
  11. by   tex
    Well on one hand you are correct, it is much easier for someone else to do it, but on the other- when I am signing my name to a document, espically based on an assessment that I am spending my time and effort on, I want to know down to the 5th digit what is wrong with my resident. The people that usually that do this data entry for the ICD codes are not nurse, that worries me. It worries me even if they have so to speak training as a med tech/clerk. Your generic dieases, no problem, all I have to do is click a pre exsisting list that is in the MDS paper work. Do you have MDS forms in the UK.? What type of paper work are you responsible for? Do you do care plans etc.? Tex
  12. by   Tookie
    Tex
    I am very interested in this forum and often check it out - l am at the moment just too tired coming home to stimulate any really intersting discussion in this forum - however try to and always read the threads- l wonder if that is a side effect of working in our areas - aged care - once your finished for the day too tired to talk or think about it ?--- typed with a sigh

    Tookie
  13. by   Tookie
    Soory if this is a dumb question -(thats me today ) what is MDS - not sure what the initials are for

    Thanks Tex
    Tookie
  14. by   Sleepyeyes
    Medical data sheet??
    Medical dx sheet?

    i think??

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