Sepsis coding can be challenging due to its complex presentation and evolving diagnostic criteria. These reference sheets for Sepsis-2 and Sepsis-3 provide a clear outline of criteria for coders to accurately determine when sepsis should be diagnosed and coded. Use these sheets as a quick, reliable tool to support accurate and consistent sepsis coding.
Reading over the rules and consulting the medical decision-making (MDM) table is one way to get acquainted with the evaluation and management (E/M) office visit guidelines. But to really learn the E/M office visit guidelines, there is nothing better than seeing how they are used in real life. The following code scenario will help you to do just that. In it, you’ll find a rationale so you can see the decision-making process that went into selection of each MDM element.
Coders can use these reference sheets for creating relevant and compliant queries. This resource, which serves as an invaluable tool for anyone looking to navigate the complexities of querying, was taken from the HCPro webinar “Comply with Me: A Journey to Compliant Query Practice”, presented by Natalie Negro, MPH, BSN, RN, CCDS, FACHE, the corporate CDI manager at the Hospital of the University of Pennsylvania.
Reading over the rules and consulting the medical decision-making (MDM) table is one way to get acquainted with the evaluation and management (E/M) office visit guidelines. But to really learn the E/M office visit guidelines, there is nothing better than seeing how they are used in real life. The following code scenario will help you to do just that. In it, you’ll find a rationale so you can see the decision-making process that went into selection of each MDM element.
Clinical documentation, Hospital inpatient, Training
This exercise is designed to help coders practice reading and interpreting operative reports related to lower joints. As you review the operative information, your task is to assign the correct ICD-10-CM and ICD-10-PCS codes. Pay close attention to the specific terminology used in the report, including diagnoses, procedures, and any relevant anatomical references, and remember to reference coding guidelines. Once you have filled in your codes, you may scroll further down to reveal the answers.
Clinical documentation, Hospital inpatient, Training
These tables of new ICD-10-PCS codes (from all sections excluding the Medical and Surgical section) are organized by body system and operation for easy use that will allow coding professionals to quickly find the new codes.
Clinical documentation, Hospital inpatient, Training
These tables of new ICD-10-PCS codes in the Medical and Surgical section are organized by body system and operation for easy use that will allow coding professionals to quickly find the new codes.
Clinical documentation, Hospital inpatient, Training
Multiple organ dysfunction syndrome (MODS) is a severe condition characterized by the failure of more than one organ system, often induced by a critical illness or injury. Because MODS does not have a specific ICD-10-CM code, coders face the challenge of capturing the full complexity of the condition. As a result, each organ dysfunction within the syndrome must be individually identified and coded.
Understanding the various organ systems involved and recognizing the specific dysfunctions can help coders accurately report the condition, ensuring precise documentation and contributing to better clinical outcomes. Below are characteristics for the dysfunctions of commonly affected organs so that coders know what to look for in the medical record.
