Most coders know that reporting a complication of care requires that the medical record include explicit documentation of the relationship between the condition and the procedure. Previous versions of the ICD-9-CM guidelines include this requirement in Chapter 17 (Injury and Poisoning),...Read More »
Q: Should we query for the specific pulmonary exacerbation of cystic fibrosis (CF)? Coding Clinic states that the exacerbation of CF should be listed first.
A: ICD-9-CM codes for CF (i.e., 277.00-277.03) are combination codes. ICD-9-CM code 277....Read More »
Physicians in the ED setting must make observations and determinations rapidly. Differential diagnoses often precede hospital admission. Sometimes all you have are symptoms, but you know the patient is very sick. Sometimes you know exactly what that sickness...Read More »
Q:A patient with a long history of Type I diabetes is admitted after a syncopal episode. Urine culture grows greater than 100,000 E. coli, and the physician documents a diagnosis of urinary tract infection (UTI) treated with PO Bactrim. If the physician documents the...Read More »
ICD-10-CM/PCS incorporates laterality, acuity, anatomical specificity, and a slew of additional combination and complication codes. Who will submit queries when this information is missing in a medical record? Will coders or CDI specialists take on this role? Perhaps it might be a combination of...Read More »
The HIM profession is constantly changing. The delivery of healthcare is in flux, as are documentation requirements and payment for healthcare services.
In the first edition of Manual for Medical Records Librarians,...Read More »
