Verbal conversations with providers regarding reportable conditions and procedures are considered verbal queries. Refresh how they should be memorialized within the record to maintain compliance. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: A patient has acute renal failure due to dehydration, a history of Type 1 diabetes mellitus causing end-stage renal disease, a kidney transplant two years ago, and chronic kidney disease stage 3a, immunosuppressed by their drugs. How would this be reported in ICD-10-CM?
A Journal of the American Medical Association study found that ICD-10-CM influenza codes accurately represented cases of positive diagnoses in pediatric patients, but their sensitivity was modest.
Brandi Hutcheson, RN, MSN, CCM, CCDS, CCA , examines the coding and clinical literature on malnutrition and obesity to see how coders can reconcile these seemingly disparate diagnoses.
Managing chronic conditions requires involvement from many parties, making documentation challenging. Assess how to improve documentation and reimbursement for chronic conditions with tips provided by Arta Kelmendi-Doko, MD, PhD . Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Nancy Reading, RN, CPC, CPC-P , explains how understanding liver disease and its many complications is key to supporting higher-specificity ICD-10-CM coding and reimbursement.
Many CDI professionals are familiar with the saying that, since CDI is “already in the chart,” they can easily pick up a new review lens. The reality, however, is that each new responsibility can put a damper on staff bandwidth and productivity.
Q: A 64-year-old female bilateral lung transplant recipient presents with aspiration pneumonia, hypoxia, and has immunosuppression from the drugs. How would this scenario be reported in ICD-10-CM?
Despite the expansion of codes that came with the transition from ICD-9 to ICD-10-CM, the majority of codes for inflammatory arthritis were not frequently used in 2015 through 2021, researchers found.
Pressure injuries, which can lead to a patient safety indicator (PSI), require clear documentation and coordination among coding, CDI, and clinical departments. Katherine Siemens, RN, BSN, CMSRN, CCDS , evaluates how poor coordination could result in a PSI being incorrectly reported.