Respiratory failure, whether acute or chronic and whether following surgery or not, is one diagnosis that is always an easy target for those who abuse the documentation and assignment of ICD codes.
In the third part of our series on Patient Safety Indicator 90, we focus on inclusions, exclusions, and coding and documentation vulnerabilities for PSI 7.
Many coders and CDI specialists memorized previous Official Guidelines for Coding and Reporting , Coding Clinic for ICD-9-CM and do not have to give them a lot of forethought before applying correctly to their day-to-day reviews. Although many of the Official Guidelines for Coding and Reporting remain the same in ICD-10, none of Coding Clinic's previous advice can be applied to the new code set. Without years of new Coding Clinic advice under their belts, it may take some time before the staff exhibits the same ease when applying ICD-10-CM/PCS codes to the documentation provided.
Inpatient coding professionals are used to DRG systems where all of the diagnoses and procedures map to a single DRG. So they may not look for additional procedures and services to report outside of that DRG.
Beginning January 1, 2015, physicians will no longer need to provide certification for an inpatient admission unless the admission is expected to last for at least 20 days or the case is an outlier.
Many coders rely on the advice in the American Hospital Association (AHA)'s Coding Clinic to resolve sticky situations with ICD-9-CM coding. However, the AHA will not be transitioning its current guidance to ICD-10-CM. Instead, in January, it began focusing solely on ICD-10-CM questions to help clear up confusion prior to implementation.
