When the term ‘sepsis syndrome’ is documented coders and CDI specialists have to query the physician. That’s the latest guidance from Coding Clinic for ICD-9-CM released in its 2nd Quarter 2012 edition pp 21-22. The article states, “The term ‘sepsis syndrome’ is poorly defined...Read More »
Q: I need further clarification regarding documentation of toxic metabolic encephalopathy. I’m trying to code two different cases in which a physician documents acute mental status change...Read More »
Editor’s Note: AHA Coding Clinic for ICD-9-CM released its second round of ICD-10 coding guidance in its First Quarter 2013 issue. HCPro CDI Education Director Cheryl Ericson, MS, RN, CCDS, CDIP, says the guidance contains information regarding diagnosis clarification,...Read More »
In thinking about all the initiatives swirling around the industry, I realize that CDI specialists can become quite confused as they attempt to juggle the increased workload. Core measures, present on admission, patient safety indicators,...Read More »
Q:I realize that if the body mass index (BMI) of a patient is documented by nurses and dieticians can be coded if the physician documents the clinical significance (i.e. morbid obesity). However, if the BMI is documented by a patient care tech or nursing ward secretary...Read More »