Garry L. Huff, MD, CCS, CCDS, and Brandy Kline, RHIA, CCS, CCS-P, CCDS, provide an overview ofkey information providers need to document for coders to assign proper codes for chronic kidney disease and acute kidney injury.
Coders need to understand the clinical presentation of sepsis to report it accurately. Robert S. Gold, MD, and Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, review how to identify sepsis and tips for coding it in ICD-10-CM.
CMS does not require ordering providers to rewrite orders prior to ICD-10 implementation with appropriate diagnosis codes for laboratory, radiology, and other services, including durable medical equipment, prosthetics, orthotics, and supplies, according to a new FAQ.
Q: In terms of coding blood transfusions, does the documentation of which intravenous (IV) site used have to come from the physician in the progress note or can this particular information be extrapolated from nursing notes, orders, etc.? As far as I can tell, a blood transfusion is usually administered to whatever peripheral IV line/site is available, unless otherwise contraindicated or instructed differently by a specific physician order.