Q: In ICD-10-PCS, which root operation would we report for an obstetrical delivery? Would it change for a cesarean section versus a manually assisted vaginal delivery?
Q: When atelectasis is noted on an ancillary test such as a CT scan of the abdomen or chest x-ray, can nursing documentation of turning, coughing, and deep breathing be considered an intervention that qualifies as one of the criteria to meet a secondary diagnosis?
Q: Can you explain when a neoplasm should be listed as the principal diagnosis? We have some coders who believe the neoplasm should always be the principal diagnosis.
QUESTION: Can a patient have encephalopathy after surgery? For example, a patient becomes confused post-surgery and is transferred from the medical-surgical floor to the intensive care unit, where he or she receives high doses of pain medication via IV. However, the patient recovers well and the confusion disappears after the IV fluids and reduction in pain medication and oxygen. Would it be appropriate to query the physician regarding encephalopathy and its possible cause, or would this be a red flag for auditors? The situation did extend the patient’s length of stay by one day.
Q: Our physicians document a diagnosis of pneumonia but do not normally make a specific connection with the patient's ventilator status, even when this is obvious from the record. For example, the patient's been on the ventilator support immediately prior to the diagnosis. Can I report this as ventilator-associated pneumonia in ICD-10-CM without the documentation specifically connecting the conditions?
Our experts answer questions on port reassessment, laparoscopies, reporting multiple biopsies, rejected drug claims, post-reduction film, nipple revisions, and more.
Q: I have been asked to build a query for a diagnosis of SIRS and/or sepsis for the following scenario: The patient was admitted for an infection urinary tract infection (UTI), pyelonephritis (PNA) and meets two SIRS criteria. The patient may be treated with oral or intravenous antibiotics, and may be on a general medical floor (not intensive care). The physician did not document SIRS or sepsis. I am having a hard time with this query because I am not sure if this would be considered adding new information to the chart or leading the physician by introducing a new diagnosis. Do you have any suggestions?
