Q: We are currently coding a chart for an acute kidney injury which has the baseline serum creatinine and urine output missing from the chart. Is there something we can do to identify additional information before we have to query the physician?
By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS
When CMS told the American Medical Association (AMA) physicians could have a one-year grace period to become comfortable with ICD-10-CM/PCS coding systems, they made a bad decision. The agreement allowed providers to be less...Read More »
Q: We have started receiving rejections for ED claims when the service involves removing impacted cerumen. We are reporting CPT® code 69209 (removal impacted cerumen using irrigation/lavage, unilateral) for each ear, and the documentation supports the irrigation/lavage rather than the...Read More »
The selection of the principal diagnosis is one of the most important steps when coding an inpatient record. The diagnosis reflects the reason the patient sought medical care, and the principal diagnosis can drive reimbursement....Read More »
