Q: What is the correct procedure code for an esophagogastroduodenoscopy? Our coder coded 0DQ68ZZ (Repair, stomach, via natural or artificial opening, endoscopic), which groups to DRG 326, the same as an esophagectomy. The relative weight is 5.45. This does not seem right. Could you please clarify?
Q: I am never sure of correct sequencing when the admission is for flu, pneumonia, and asthma. The patient presented in the emergency department (ED) with shortness of breath, still tight after nebulizer treatment in the emergency room. The patient was kept for observation for one day, then was admitted. Documentation includes: Fever 101.8 in ED; respiratory rate (RR) 24; white blood cell count (WBC) 12.6 Influenza and upper respiratory tract infection Mild persistent asthma in exacerbation due to the above (wheezing, tachycardia in the ED, 130s); acute hypoxic respiratory failure (PO 90%). Superimposed RLL community-acquired pneumonia (CAP), per chest x-ray Can you suggest proper sequencing and if queries are needed?
Q: I am with a CDI program that is starting to explore severity of illness/risk of mortality (SOI/ROM). I personally have been reviewing for SOI/ROM for quite a while. I usually designate the impact (MCC/CC/SOI/ROM) after the billing is done and see if what I queried for made a final impact, and only take credit for those that do. I was told that regardless of the actual final impact on SOI/ROM, we should be taking credit for any SOI/ROM clarification as SOI/ROM impact. Which is the most accurate, “correct” way to capture the CDI impact for these types of clarifications?
Q: During an ICD-10-PCS Fusion, when a physician documents the use of a “structural allograft spacer” in the medical record, what sixth character would we use when coding this? Some colleagues say to use A (interbody fusion) and some say to use K (nonautologous tissue substitute). What would be the correct way to code this?
Q: What exactly are diagnostic-related groups (DRG) 067 and 068 (nonspecific cerebrovascular accident [CVA] and pre-cerebral occlusion without infarct, respectively)? How do they differ from transient ischemic attack (TIA) or CVA?
Q: Is it appropriate to assign ICD-10-CM code Y95 (nosocomial condition) based on the documentation of healthcare-associated pneumonia (HCAP) or hospital-acquired pneumonia (HAP)? It is appropriate to assign the code for documented healthcare-associated conditions. Should this still be queried for specificity, and should the hospital-acquired condition (i.e., pneumonia) be coded as bacterial, viral, or something else?
Q: When a patient presents with acute respiratory failure, as well as an overdose, is it ever appropriate to assign the acute respiratory failure as principal diagnosis, since it is an acute condition that would have occasioned the admission to the hospital?
Q: I am never sure of correct sequencing when the admission is for flu, pneumonia, and asthma. Can you suggest proper sequencing, and if queries are needed?
Q: I have a patient with stage IV lung cancer that presented with fatigue, cough, and loss of appetite. Initially, they thought he had pulmonary nodular amyloidosis, but when they did an echocardiogram on day one they found a pericardial effusion. How would this be sequenced and coded?
Q: We are currently using a hybrid medical record, so we have standard query forms with multiple-choice options that cannot be modified at this time. We wanted to include a statement so our query doesn’t seem leading. Is our approach to the multiple-choice query format appropriate?
Q: We have a teenager with systemic lupus erythematosus and history of lupus nephritis who came into the ED with seizures. The physician admitted the patient with documentation of with status epilepticus and hypertensive urgency. The intensivists then documented hypertensive encephalopathy. What should we choose as the principal diagnosis?
Q: We are having trouble determining how to assign a code for a pressure ulcer that begins as a Stage I concern that is present on admission (POA) but advances during the patient’s stay to a Stage II or a Stage III. Coding Clinic, Fourth Quarter 2008, p. 194, tells us that even if the ulcer advances it would still be coded as POA, but would even an advanced stage still be considered POA?
Q: Can you clarify the expectations related to documenting the discussion between a physician and a clinical documentation improvement specialist when a query is done verbally? The 2013 ACDIS/AHIMA physician query practice brief Guidelines for Achieving a Compliant Query Practice expanded on the need to document this interaction and we’re wondering if our process is compliant.
Q: Our physicians sign off on diagnoses that the nursing staff prepares on admission of a new patient, can you suggest a process to capture all relevant diagnoses?
Q: In the past few weeks, we noticed physicians are documenting acute congestive heart failure with preserved ejection fraction instead of diastolic or systolic. They say the heart failure is not diastolic or systolic. What is the best way to approach this issue?
Q: Our facility is developing clinical definitions regarding types of atrial fibrillation (afib) given the specificity changes in ICD-10. Could you provide suggestions for these definitions? Do you think it is appropriate to query for persistent atrial fibrillation for the period of more than seven days and chronic afib sustained for more than 12 months Are you aware of any strategies other institutions are using when querying regarding afib?
Q: I was reviewing a case with one of our clinical documentation improvement (CDI) specialists this morning. The following clinical indicators documented in the chart are elevated cardiac enzymes, shock, and demand ischemia. Cardiology documented “elevated cardiac enzymes in setting of shock representing a Type 2 injury.” Also documented in another note is “demand ischemia.” Should the CDI specialist query for more information?
Q: CMS released guidance last summer about not auditing or counting errors for the specificity of an ICD-10-CM code. CMS is not going to count the code as an error as long as the first three digits are correct. Does this apply to medical necessity diagnoses and edits?
