MLN Matters article SE1121 emphasizes that coders must consider all documentation from licensed treating physicians and attending physicians when assigning a principal diagnosis. It states:
“The emergency room report, history and physical (H&P),...Read More »
What is the correct principal diagnosis in the following case? A 59-year-old male with history of (h/o)bladder cancer and failure to follow up was admitted for video-assisted thoracic surgery (VAT) for pulmonary nodules found on imaging. The patient had the VAT procedure and a pulmonary wedge...Read More »
Q: I have a question regarding sequencing. I would usually have sequenced 428.21 (heart failure) as principal diagnosis, but I was advised by my inpatient coder that she would sequence 404.91 (Unspecified hypertensive heart and renal disease with heart failure) as the principal...Read More »
There has been a considerable amount of confusion regarding physician terminology, documentation
requirements, and subsequent coding of various diagnostic bronchoscopic lung procedures. Because the current MS-DRG structure categorizes some of...Read More »
While most CDI specialists know to query for conditions related to malnutrition, such as obesity and cachexia, programs frequently ignore dietitians’ documentation and keep dietary professionals out of the coding/querying conversation when they should be partners at the table.Read More »
The American Hospital Association (AHA) does not plan to “convert” past issues of Coding Clinic for ICD-9-CM into new issues for ICD-10-CM/PCS, the AHA confirmed in a CMS teleconference held in November 2011. This decision caused concern...Read More »
In October 2010, when ACDIS first conducted its assessment survey regarding CDI readiness for ICD-10 implementation, 83% of respondents indicated they had no formal ICD-10 training and 44% indicated they had no training timeline (www.hcpro.com/...Read More »
This month’s question was submitted on January 2, 2024, and focuses on CDI metric expectations, reporting, and education. Please note that questions and answers have been de-identified for the purposes of this article.
Q: I have a couple of questions regarding CDI metric...Read More »
