Not feeling well? The problem could be in your small intestine. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, reviews common conditions related to the small intestine.
In ICD-10-CM, coders will use a seventh character, not an aftercare code, to identify follow-up treatment for an injury. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, C-DAM, Kristi Pollard, RHIT, CCS, CPC, CIRCC, and Anita Rapier, RHIT, CCS, explain how aftercare coding will change in ICD-10-CM.
Q: What advice can you offer for sequencing pulmonary edema and congestive heart failure when both appear to meet the definition of principal diagnosis?
Most hospitals have been overwhelmed by Recovery Auditor (RA) requests for documentation. So it's no surprise that the RAs themselves seem to be equally as burdened with the task of processing those records.
Q: I’ve heard that queries differ between critical access and short-term acute care hospital settings. Is this true, and if so, where can I find more information?
In the third part of our series on Patient Safety Indicator 90, we focus on inclusions, exclusions, and coding and documentation vulnerabilities for PSI 7.
The ICD-9-CM guidelines state that it's unusual for two or more diagnoses to meet the definition of principal diagnosis. However, coders know this isn't exactly true, as the scenario tends to occur frequently.
Patients aren’t the only ones paying attention to quality scores these days. Payers are, too. Cheryl Manchenton, RN, BSN, and Audrey G. Howard, RHIA, explain why coders and clinical documentation improvement specialists must understand which conditions affect provider profiles.
Shannon Newell, RHIA, CCS, Steve Weichhand, and Sean Johnson conclude their four-part series on PSI 90 with an in-depth look at PSI 12, which evaluates a hospital’s risk adjusted rate of perioperative deep vein thrombosis and/or pulmonary embolism in surgical discharges for patients 18 years and older.
Q: I need further clarification regarding documentation of toxic metabolic encephalopathy. I’m trying to code two different cases in which a physician documents acute mental status change secondary to an infectious process . In each case, the patient’s metabolic panels don’t appear to be abnormal; however, one of the patients is septic. The physician thinks that documenting and coding sepsis separately from encephalopathy would result in unbundling. However, I disagree because coding the sepsis separately demonstrates severity. What is the correct logic to use in each of these cases?
