Q: A patient is admitted with a high white blood count, tachycardia, tachypnea, and chills. The blood culture shows positive for methicillin-resistant Staphylococcus aureus (MRSA). The attending physician documents MRSA sepsis in the progress notes. Antibiotics are changed based on the blood culture and the patient is treated with appropriate antibiotics. Due to poor vascular access, a central venous catheter (CVC) is inserted and antibiotics are infused through this access. The patient responded slowly to treatment and CVC access becomes red and inflamed. The catheter is removed and cultured. The physician documents this to be an infection due to MRSA. What’s the diagnosis code for this?
Q: Our physicians document a diagnosis of pneumonia but do not normally make a specific connection with the patient's ventilator status, even when this is obvious from the record. For example, the patient's been on the ventilator support immediately prior to the diagnosis. Can I report this as ventilator-associated pneumonia in ICD-10-CM without the documentation specifically connecting the conditions?
Q: Does the physician have to document the stage of a decubitus ulcer or can it be a wound care nurse? Does that person have to document stage 1 or can he or she describe the wound?
Q: Can you explain when a neoplasm should be listed as the principal diagnosis? We have some coders who believe the neoplasm should always be the principal diagnosis.
Q: In ICD-10-PCS, which root operation would we report for an obstetrical delivery? Would it change for a cesarean section versus a manually assisted vaginal delivery?
Q: Can you ask a yes or no question in a query based on clinical information from a previous echocardiogram report or other diagnostic result from a previous admission?
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?
Q: A patient presents with altered mental status/encephalopathy due to a urinary tract infection (UTI). The patient has a history of dementia. The final diagnosis is encephalopathy due to UTI. Should we code the encephalopathy as a secondary diagnosis because it’s an MCC and not always a symptom of a UTI?
Q: A patient undergoes placement of a MediPort ® to receive chemotherapy for lung cancer. What principal diagnosis should we report? Should we report V58.81 (fitting and adjustment of vascular catheter) or 162.9 (malignant neoplasm of bronchus and lung unspecified)?
Q: Our facility has a question about how other hospitals address this scenario: Patient is discharged to home (discharge status code 01). No documentation exists in the medical record to support post-acute care. Several months later, our Medicare Administrative Contractor (MAC) notifies us that the patient indeed went to post-acute care after discharge. The MAC retracts our entire payment. We need to resubmit the claim with the correct discharge status code. We are reluctant to do so because nothing in the medical record supports the post-acute care provided. Are other hospitals amending the record? If so, which department is adding the amended note?
Q: Which ICD-10-CM external cause code should we report if a patient falls while on an escalator? This is the first time that the patient has been seen for such a fall.
Q: Some of our providers see patients in our local nursing facilities. When these patients are admitted to our hospital, must we retain this documentation in our own records?
