Q: The primary physician documented subacute cerebral infarction and I am wondering whether I should code this to a new cerebral vascular accident (CVA) or not, since the term “subacute” doesn’t really fall anywhere.
ICD-10-PCS will change the way coders count sites for coronary artery bypass graft (CABG) procedures. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Nena Scott, MS, RHIA, CCS, CCS-P, explain how coders will report CABG in ICD-10-PCS.
Q: Can CDI programs use the information on ambulance forms or trip tickets to abstract from if the information is pulled into or reiterated in the ED or history and physical (H&P) documentation? Our staff doesn’t want to miss criteria that would diminish our ability to substantiate the true severity of illness of some patients, but I have been informed that coders are not allowed to code from ambulance papers or information.
CMS and auditors are increasing scrutiny of CCs and MCCs. William E. Haik, MD, FCCP, CDIP, provides tips that coders can use to look for clinical evidence in the record before querying for these targeted conditions.
QUESTION: Do you predict coder productivity will decline as a result of ICD-10? If so, what do you think the declines will be six months after implementation?
Depending on the demographics of the region a hospital serves, its coders could determine code assignment for hundreds of deliveries and pregnancy-related services annually. Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, COBGC, and Susan Proctor, RHIT, CCS, CPC, review the relevant coding guidelines for coders who handle coding for these patient encounters.
Q: Should we query for the specific pulmonary exacerbation of cystic fibrosis (CF)? Coding Clinic states that the exacerbation of CF should be listed first.
