Coder Meeting November 2010
Agenda • Calls • Conference call: (888)285-4585 • Host code: 745418 Participant code: 531590 • Announcements • NICU / Transfer consistency • Coder Fax • October 2010: Dr Timothy Stevens • September 2010 • August 2010 • July 2010 • Insurance questions: Mary Ellen Britt
Announcements • NYSDOH response to Gazetteer question: This is something I have been advocating for years. This is very high on my wish list given the importance of proper geo coding. However, this is an enormous undertaking and given the state's financial crisis and dwindling resources it will not happen in the near future. • I have suggested to others that they contact the tax assessor's office and request of list of street names within the city town or village to aid them in assigning the correct location. • NB Screening program number error • Leave number blank – reason “illegible” • Need full chart for March review
Announcements INFANT FEEDINGDuring the period between birth and the fifth day of life (or discharge from the hospital if the infant is discharged before the fifth day of life), indicate whether the infant hasbeen fed breast milk exclusively, infant formula only, a combination of both breast milk and formula, or other. • Breast Milk Only: (Exclusive breast milk feeding) Infant has been fed ONLY breast milk and noother liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines.Breast milk feeding includes expressed mother’s milk as well as donor human milk, both of whichmay be fed to the infant by means other than suckling at the breast. • Formula Only: Infant has been fed formula (any amount). Has NOT been fed any breast milk. May or may not have been fed other liquids, such as water or glucose water. • Both Breast Milk and Formula: Infant has been fed BOTH breast milk (any amount) ANDformula, water, glucose water and/or other liquids (any amount). • Other: Infant has NOT been fed any breast milk or formula. This response is rare; it will includeinfants in the intensive care unit who require intravenous feeding.
Announcements • At our September Coder meeting several in attendance complained that when entering data in the evening transitioning from one screen to the next is very slow. • When does this happen?
October Coder Fax 2010 N = 19 18 1 17 11 15 ? ? 19 1 blank – no anesthesia record 14 4 19 19 19 1 15 10
October Coder Fax 2010 Shoulder dystocia occurs when, after delivery of the fetal head, the baby's anterior shoulder gets stuck behind the mother's pubic bone. If this happens, the remainder of the baby does not follow the head easily out of the vagina as it usually does during vaginal deliveries. Clarification by Dr Glantz: • Shoulder dystocia usually is not necessarily traumatic--the object is to try to minimize potential trauma, although sometimes this is not possible. In most cases of shoulder dystocia, however, the baby is not injured. • For clavicular fracture, (a) these can occur for no apparent reason, such as after uncomplicated deliveries during which there was no manipulation or obvious stress on the clavicle, and (b) they are not serious and heal well, leaving no lasting sequelae.
P3 October Coder Fax 2010
October Coder Fax 2010 P3 P1
July Coder Fax 2010 N=18 4 14 18 12 2 5 7 11 17 1 1 18 16 1blank 18
P2 July Coder Fax 2010
August Coder Fax 2010 16 N = 18 2 7 11 3 1 10 10 1 17 16 2 15 3 18 10 1 17 18 17 1
August Coder Fax 2010 P3 P4
August Coder Fax 2010 P1 P3
August Coder Fax 2010 P4 P2
August Coder Fax 2010 P4 P3
September Coder Fax 2010 VTX, vertex= cephalic N = 16 1 15 1 16 16 16 2 16 2 16 14 9 6 1 Blank 1 Blank 1 Blank 16 15 1 13 2 =37.4 15 3
September Coder Fax 2010 P1 P2 Ancef Dose 2 GM Route; IVGive during: Labor