Codes for epilepsy and migraine headaches are getting a makeover for ICD-10-CM. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, reviews the additional specificity in the new ICD-10-CM codes.
Q: My colleagues and I continually wrestle with this question: Must all diagnoses on an inpatient chart be listed in the discharge summary for them to be coded?
Everyone knows that CCs and MCCs are under scrutiny these days. However, that doesn't mean hospitals should err on the side of caution when reporting these conditions. William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Fla., provides several tips that coders can employ to look for clinical evidence in the record before querying for these targeted conditions.
The task of assigning the appropriate present on admission (POA) indicator for various conditions is still fraught with a number of challenges—many of which stem from problems coders have in obtaining clear, explicit physician documentation. Colleen Stukenberg, MSN, RN, CCDS, CMSRN, and Donna D. Wilson, RHIA, CCS, CCDS, discuss how gleaning the necessary details from the records can be a daunting task in and of itself, and then inconsistencies among various physicians makes assigning POA indicators that much harder.
