Clinical Documentation Improvement staff often send queries to determine cause and effect between infections and a device, implant or graft. Why is this important?
First, if the infection was present on admission and related to a device, it changes the DRG (diagnosis group). Second, it is imperative to clearly identify POA status because it is a hospital-acquired condition (HAC), if it wasn’t POA.
For example, if a patient was admitted with a UTI and has a chronic Foley, a query must be written to see if the UTI was due to the Foley or if it was unrelated. Other examples include sepsis due to an infected dialysis catheter or a MRSA infection due to a joint replacement.
Devices, implants, or grafts include catheters (Foley, nephrostomy, suprapubic, PICC, CVC, dialysis, etc.), internal joint prosthesis or fixation devices, vascular anastomosis and bypass, or pacemakers.
Many physicians have started adding POA statuses to their diagnoses; we love seeing this! It strengthens your documentation and helps ensure correct reimbursement. We have a wonderful team of physicians who continually strive for excellence, and we thank you for all your hard work.