As the largest organ in the body, the skin is subject to a number of diseases and conditions. With ICD-10-CM, coders will report these conditions with a much higher degree of specificity.
Thirty-day readmissions for heart failure, heart attack, and pneumonia occur most frequently for reasons other than the cause of the initial hospitalization, according to a study published in the January 23 issue of the Journal of the American Medical Association (JAMA).
Information received by TMF Quality Institute during the past year indicates that 61% of hospitals use PEPPER data to guide their auditing process and help them focus on areas of potential vulnerability.
Q: A patient presents with a sore throat, and the physician states “Sore throat; differential diagnoses include streptococcal sore throat, tonsillitis, postnasal drip.” If the physician doesn’t rule out any of the differential diagnoses, should the coder query for clarification or simply choose one of the differential diagnoses?
Coding managers and their team members sometimes must approach physicians in person regarding documentation. Clarification may be necessary, or perhaps you will need to coax the physician to complete certain records without further delay.