Q: What clinical documentation is acceptable to pull Hierarchical Condition Category (HCC) information from for reporting purposes? Would you code from history of present illness, past medical history, active problem list, or the assessment?
What’s a physician’s favorite radio station? When it comes to coding compliance and revenue cycle management of their practices, WII-FM, What’s In It For Me, is what physicians listen to.
Physician salaries have traditionally...Read More »
Q: If the attending documented, “likely mixed cardiogenic and septic shock,” can I assign codes R57.0 and R65.21?
A: Refer to the documentation within the code book. If you open the book to the R57 code grouping (Shock not elsewhere classified) listed...Read More »
Q: If you have an acute exacerbation of a chronic right heart failure (CHF) with a preserved ejection fraction (EF)— above 55%—can you code it as heart failure with preserved EF? All the clinical symptoms are exemplifying right failure. For example, ascites, pronounced neck vein...Read More »
by Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS
Congestive heart failure (CHF) is a commonly diagnosed condition where the ventricles or the lower chambers of the heart do not work effectively. The heart serves as a pump to get blood in and then out of the...Read More »
