QUESTION: Recently, reviewers have denied diagnostic code 584.9 (acute renal failure [ARF]) based on lab values. The diagnosis is well documented and treated by the attending physician, but reviewers are stating the lab values do not support the diagnosis of ARF. The lab values (creatinine/blood urea nitrogen) went from normal to abnormal, and we found no definitive standards for lab parameters to meet the definition of ARF. Following coding guidelines for reporting secondary diagnoses, the ARF was clinically evaluated, the patient received therapeutic and diagnostic procedures, and there was an extended length of stay/increased nursing care. As coders, we feel it is inappropriate to question the physician’s clinical judgment, and reporting the ARF as a secondary diagnosis is correct. Based on the documentation in the record, is it appropriate to code the ARF?
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.
QUESTION: For a healing traumatic finger amputation with concern but no diagnosis of infection at the amputation site (the physician prescribed Bactrim), is it correct to assign code V54.89 (other orthopedic aftercare) and ICD-9-CM code 886.x (traumatic amputation of finger)?
The UHDDS defines principal diagnosis as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. That means the principal diagnosis is not always the condition that brought the patient into the hospital.
Q: Using the ICD-10-CM guidelines for the seventh character extensions for fracture codes, how should I identify each of the following? Avascular necrosis following fracture Cast change or removal Emergency treatment Evaluation and management by a new physician Follow-up visits following fracture treatment Infection on open fracture site Malunion of fracture Nonunion of fracture Medication adjustment Patient delayed seeking treatment for the fracture or nonunion Removal of external of internal fixation device Surgical treatment
