CO Communication Codes
Junior resident texts chief resident multiple times overnight to communicate clinical changes in patient but senior resident does not respond, junior resident ends up calling attending directly for guidance
CO1014 Communication among providers – failure to respond (to text, call, etc.)
Pt presented to ED with CP and SOB; underwent a chest CT and radiologist ruled out a PE, but failed to report incidental finding of small lung nodule
CS3020 Failure/delay in reporting incidental findings
Case marked as uncodable because it was determined to be General Liability instead of Professional Liability
XC1000 Exclude case – opened in error
RN performs incorrect surgical instrument count at completion of colostomy reversal resulting in retained clamp
TS4011 Technical performance – incorrect/inconsistent surgical count
Primary Care Clinic only has one Medical Assistant employed to assist 4 busy Family Medicine Physicians
AD1015 Adequacy of staffing *HF code*
CO1003 Communication among providers – poor professional relationship/rapport.
Pt referred to hematologist by PCP for chronically elevated WBC and platelets but failed to show for scheduled consult appt. No follow up from PCP or hematology office to reschedule appt, pt ultimately diagnosed with CML that progressed to blast stage due to delay.
CS4006 Failure in system for patient follow-up after missed consult/referral
CTS (Clinical Taxonomy Specialist) opens source documentation to code a new case and finds only legally filed summons information is available
IL1002 Information limited – writ of summons
Patient suffers broken rib during CPR that results in pneumothorax
TS4010 Technical performance – poor technique – resuscitation
Transport aide transfers patient from ICU to step down unit and leaves stretcher in hallway, does not communicate with RN staff that patient has arrived, pt stays in hallway for 3 hours
CO1013 Ineffective communication during transition of clinical setting *HF Code*
CO3005 Patient portal
RN did not check newborn ID tag against mom's when bringing newborn to nurse. Mom bonded with wrong baby
CS9007 Lack of/failure in system for patient care – patient identification
CTS begins to code an open case but quickly realizes there is limited information; source material states additional documentation is pending and will be available after staff and expert interviews
IL1001 Information limited for full coding (needs additional review)
OB uses excessive force after encountering shoulder dystocia during delivery resulting in brachial plexus injury
TS4003 Technical performance – improper use of traction during a procedure
Resident repeatedly asked by nursing staff to address other patient needs while writing a progress note; note entered into EHR with multiple errors
CJ6001 Distractions/multitasking/interruptions *HF Code*
Patient wearing portable heart rate monitor to assess recent palpitations was not contacted by remote monitoring tech despite receiving repeated "signal lost" messages from device
CO4004 Remote patient monitoring transmission
Pt underwent cxr in ED to evaluate chronic cough, she only received initial wet read findings that were reported as normal. Pt never received final read results that reported some patchy infiltrates c/w walking pneumonia
CS3011 Patient did not receive test results – initial or revised
Internal medicine resident mismanages patient's care during night shift, attending MD's involvement overnight unclear based on available source documentation
NO2001 Unclear contribution/CF for this RS role (Int Med attending)
Urgent care PA calculates and orders antibiotics at adult dose for pediatric patient with strep throat
TS2005 Medication/biologic error- computation
Pt arrived to pain clinic disoriented and became somnolent, narcotic overdose suspected. MD asked RN for Narcan, RN noted it had not been restocked. Ambulance called, delay in admin of Narcan
CS9001 Lack of/failure in system for patient care – availability of equipment, supplies, medications/biologics *HF Code*
Plastic surgeon has staff post anonymous fabricated positive reviews on plastic surgery community site resulting in increase in consultation requests
CO9001 Use of internet/social media sites
Pt with no skin breakdown on admission develops sacral pressure ulcer that progresses to infected Stage IV during hospitalization requiring prolonged wound care
CS9100 Nosocomial infection
Insured hospital provides malpractice coverage to resident physicians but not attendings. ED attending and resident treat a man presenting with abdominal pain, attending fails to diagnose appendicitis and pt suffers appendiceal rupture at home after dichrge
NI1001 Non-insured influence
A pharmacist dispenses Navane (an antipsychotic) instead of Norvasc (an antihypertensive) due to similar looking bottles and drug names, leading to severe fatigue and confusion
TS2006 Medication/biologic error-dispensing (pharmacy)
Experienced surgical RN new to ASC was unfamiliar with equipment and did not properly attach foot supports for lithotomy positioning; pt's legs gave way during positioning resulting in injury
CJ9008 Provider lacks experience – new to role/setting *HF Code*