Coders are often in the difficult position of trying to determine whether to report a CC. William E. Haik, MD, FCCP, CDIP, and Kathy DeVault, RHIA, CCS, CCS-P, discuss problems areas in documentation of CCs and what clinical indicators coders should use to help with CC reporting.
Coders may find assigning codes for sepsis somewhat easier in ICD-10-CM, but they will still face some challenges. The first of those challenges, and probably the biggest, centers on physician documentation.
The 2014 OPPS proposed rule is shorter than normal at 718 pages, but the proposed changes are significant and probably the most sweeping changes since the inception of OPPS, says Jugna Shah, MPH, president and founder of Nimitt Consulting.
Q: A patient with undiagnosed syncope is admitted to observation. Later that evening, the patient is diagnosed with syncope and develops complications that warrant an inpatient admission. Should the patient be considered an inpatient from the time inpatient criteria are met or from the time the inpatient order is written?
Despite all the uncertainty surrounding the implementation of ICD-10-CM/PCS, the Cooperating Parties (i.e., the American Hospital Association, AHIMA, CMS, and the National Center for Healthcare Statistics) nevertheless decided that the farewell issue of Coding Clinic for ICD-9-CM (which was published in the first quarter of 2014) will remain the farewell issue.
Coders can go a bit overboard when reporting CCs and MCCs. Cheryl Ericson, MS, RN, CCDS, CDIP, and Deborah K. Hale, CCS, CCDS, reveal the dangers of over-reporting CCs and MCCs and how to report them appropriately.
Coding professionals may inappropriately assign codes from parts of the medical record where the doctors, early in the workup of a complex patient, were describing differential diagnoses in their evaluation of the patient. Robert S. Gold, MD, discusses whether coders should report every diagnosis mentioned in a patient’s chart.
Q: Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase “versus” between them? For example, the patient arrives with abdominal pain and the physician orders labs and other tests, but they all come back normal. In the discharge note, the physician documents “abdominal pain, gastroenteritis versus irritable bowel syndrome (IBS).” When I first started as a CDI specialist I was told we could not use diagnoses when "versus” was stated, and that we had to query for clarification.
