Each new CMS fiscal year, MS-DRG weight and classification changes in the CMS IPPS final rule are closely scrutinized by coders and CDI specialists to identify any potential impact on documentation capture and code assignment processes.
Q: A few days into the patient’s stay, an order for a Foley catheter was placed for incontinence and around the same time the physician documented a urinary tract infection (UTI). Would it be appropriate to query the physician regarding the relationship of the UTI to the Foley? Our infection control department caught this but we did not. I am concerned about this for two reasons; first, I worry about writing a leading query and second, whether the UTI could be considered a hospital-acquired condition (HAC) if additional documentation isn’t provided.
Q: When I started as a coder, I learned that the complication code, such as from ICD-9-CM series 998 or 999, takes precedence as the reason of admission when present with another contributing condition. Is this correct, and is there any written guidance from AHA Coding Clinic for ICD-9-CM/ICD-10-CM/PCS that discusses this?
DRGs for procedures unrelated to the principal diagnosis shouldn't occur frequently. If they do, coding managers should take a closer look at coding compliance efforts to ensure accuracy and avoid costly audits.
Q: What recommendation would you give to the coder when the clinical indicators in the chart do not support sepsis but it’s in the final diagnostic statement?
Coders live in a very difficult world. They want to do what is best for their organization based on the documentation they have, but sometimes the documentation is incomplete. The patient’s clinical picture can help coders decide when a condition rises to the level of a CC.
Sequela, or late effect, is the remaining or lasting condition produced after the acute stage of a condition or injury has ended. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, reviews the correct way to code for sequelae in ICD-9-CM and ICD-10-CM.
Physicians often use the acronyms IBS (which should indicate irritable bowel syndrome) and IBD (which should indicate inflammatory bowel disease) interchangeably even though they represent completely different conditions with different treatment and prognoses.
Physicians often use different terms interchangeably when documenting sepsis. Robert Gold, MD , and Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, define the different terms and review when to query for additional clarification.
