Heart failure is the intrinsic inability of the heart to supply target organs with sufficient nutrient flow to function normally. Robert S. Gold, MD, and Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, review the clinical and coding guidelines for heart failure.
In ICD-10-CM, coders will use a seventh character, not an aftercare code, to identify follow-up treatment for an injury. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, C-DAM, Kristi Pollard, RHIT, CCS, CPC, CIRCC, and Anita Rapier, RHIT, CCS, explain how aftercare coding will change in ICD-10-CM.
Even through ICD-9-CM and ICD-10-CM/PCS are currently under a code freeze, c oders and CDI specialists still need to pay attention to what conditions are considered CCs and MCCs, as well as sequencing rules which could affect MS-DRGs.
Patient Safety Indicator 90 evaluates hospital performance for defined in-hospital complications and adverse events. Find out more about how clinical documentation and coding can affect this measure in the first of a four-part series.
The physician documented “encephalopathy” in the progress note of a patient who was admitted with a cerebrovascular accident (CVA) and/or possible seizures. James S. Kennedy , MD, CCS, CDIP, discusses what to consider when determining whether to code the encephalopathy.
ICD-9-CM and ICD-10-CM differentiate between acute and chronic meniscus tears. Kristi Pollard, RHIT, CCS, CPC, CIRCC , and Gretchen Young-Charles, RHIA, review how to code these injuries in both systems.
Q: How should the diagnosis of urinary tract infection (UTI) and encephalopathy be sequenced, specifically which diagnosis should be the principal? If physician documentation indicates that the patient came in with confusion, can encephalopathy be assigned as the principal diagnosis if it is due to the UTI and no other contributing issues are present?
Q: Can CDI programs use the information on ambulance forms or trip tickets to abstract from if the information is pulled into or reiterated in the ED or history and physical (H&P) documentation? Our staff doesn’t want to miss criteria that would diminish our ability to substantiate the true severity of illness of some patients, but I have been informed that coders are not allowed to code from ambulance papers or information.
Q: A patient comes in with a malunion of a fracture. A different physician treated the patient initially for the fracture, but the patient came to see our physician for surgery to repair the malunion. Which seventh character should we use: A for initial encounter or P for subsequent encounter for fracture with malunion?
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.
Coding tells a patient's story, based on the narrative the physician provides in his or her documentation. Accurately painting a picture of the patient's severity of illness (SOI) and risk of mortality (ROM) is essential for good patient care, and it is becoming increasingly important for quality measures and payment.
Many coders and CDI specialists memorized previous Official Guidelines for Coding and Reporting , Coding Clinic for ICD-9-CM and do not have to give them a lot of forethought before applying correctly to their day-to-day reviews. Although many of the Official Guidelines for Coding and Reporting remain the same in ICD-10, none of Coding Clinic's previous advice can be applied to the new code set. Without years of new Coding Clinic advice under their belts, it may take some time before the staff exhibits the same ease when applying ICD-10-CM/PCS codes to the documentation provided.
