Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, offers case studies to show how providers must document a diagnosis of heatstroke, in addition to symptoms, for coders to report ICD-9-CM or ICD-10-CM codes for heatstroke.
This document is a formal approach to documenting postoperative respiratory failure. It is provided by Paul Evans, RHIA, CCS, CCS-P, CCDS, of Sutter Health in San Francisco.
The attached PDF reviews documentation and coding needs for complications and establishes policies and procedures for coders and CDI professionals to follow. Created by Paul Evans, RHIA, CCS, CCS-P, CCDS, the document provides complication definitions, explains when queries are necessary, and explores specific documentation concerns about conditions such as Incidental Serosal Tear and postoperative atrial fibrillation.
Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director for HCPro in Danvers, Massachusetts, and ACDIS Advisory Board member Mark LeBlanc, RN, MBA, CCDS, Clinical Documentation Manager, at Hennepin (Missouri) County Medical Center, donated this sample ICD-10-CM fracture query.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, provided these examples for anemia documentation for OB/GYN patients and the questions coders to ask in order to report the correct diagnosis.
Deborah K. Hale, CCS, CCDS, president of Administrative Consultant Service, LLC, in Shawnee, Okla, provided this pocket card to use when determining whether a patient should be admitted.
This attached pneumonia documentation decision tree, courtesy of Gina Spatafore of Waterbury Hospital, is designed to help physicians document pneumonia, unspecified to the highest degree of specificity. It was originally published on the Association for Clinical Documentation Improvement Specialists website.
