Hospital inpatient

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.

Q: Can a coder or clinical documentation improvement (CDI) specialist introduce a new diagnosis as an option in a multiple-choice question?

Medical necessity denials traditionally focus on high-dollar DRGs, such as those for hip and knee replacements; others may also soon become targets.

Unfortunately, ICD-10-PCS is not very comparable to the current ICD-9-CM volume 3 codes inpatient coders currently use. But coders shouldn’t despair, according to Sandy Nicholson, MA, RHIA, Jennifer Avery, CCS, CPC-H, CPC, CPC-I and Robert S. Gold, MD —ICD-10-PC coding may even be fun once coders get the hang of it.

Q: How have you handled situations when specialty physicians and hospitalists do not agree with diagnoses impacting core measures?

Robert S. Gold, MD, explains when to skip the query on heart failure.

CMS released its FY 2014 IPPS final rule in August, and with it comes a whole slew of changes for inpatient hospitals. Set aside a good amount of time to scroll through the 2,000-plus page document. Yes, that's right: There are more than 2,000 pages of information to absorb before the rule goes into effect on October 1, 2013.

Coding Clinic serves as the Supreme Court in interpreting ICD?9?CM or ICD?10?CM/PCS and their guidelines. James S. Kennedy, MD, CCS, CDIP, Kyra Brown, RHIA, CCS, and Nelly Leon-Chisen, RHIA, discuss the best ways to use this additional guidance.

Q: Can you explain how the recent updates to the three-day payment window pertain to self-administered drugs?

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.