Q:If the physician writes septic shock instead of sepsis do I need to query for sepsis or is this an integral part and sepsis would be the principal diagnosis and the septic shock would be secondary, making it a MCC?
There are many articles about the enhanced documentation required in ICD-10-CM. However, the real challenge will be ICD-10-PCS. It is a completely new code set and is not used in any other country than our own. ICD-10-PCS does not include...Read More »
Q:The primary physician documented subacute cerebral infarction and I am wondering whether I should code this to a new cerebral vascular accident (CVA) or not since the term “subacute” doesn’t really fall anywhere.
CMS issued new guidance last week aimed at clarifying the so-called “two-midnight rule” finalized in the 2014 IPPS. The rule essentially states that physicians should order an inpatient admission if he/she expects the care...Read More »
Inpatient coders are accustomed to assigning a present-on-admission (POA) indicator in ICD-9-CM and they will continue to do so in ICD-10-CM. Although the POA indicators remain the same, ICD-10-CM includes a list of codes that...Read More »
Striving for the correct DRG assignment on the first pass should be every coder’s goal. This is not simple, and a close look reveals that the complexity of coding rules and the quality of documentation in facilities sometimes make...Read More »
Low hemoglobin and the need for erythropoiesis stimulating agents (ESAs) indicated an increased risk of mortality for children on dialysis, according to a study in the Journal...Read More »