Created Dec 2019
Query
When procedures are performed on the ward and only documented in the progress notes, such as dressing of burn in a burns bathroom, if IV midazolam is given before the procedure can we interpret this as ‘IV sedation’, hence we need to code ‘dressing of burn’ as per ACS 1911 Burns?
Response
Yes. Ideally the clinical documentation should state that the IV midazolam was administered for sedation. However, based on Clinical Coders’ Creed, if IV midazolam was given directly before the procedure and no other reason is documented as to why it was given, then the IV midazolam can be interpreted as IV sedation administered for the procedure performed and the dressing of burn will be coded as per ACS 1911 Burns.