If a coder reviews the chart of a patient in the emergency department (ED) or intensive care unit with documented symptoms, such as fever (or low temperature), elevated white cell count (or low white cell count), altered mental status, evidence of an...Read More »
Congestive heart failure (CHF) is one example of a condition for which coders and CDI specialists should understand clinical indicators before querying physicians, says Lynne Spryszak, RN, CCDS, CPC-A, a CDI educator at HCPro, Inc., in Marblehead, MA.
Over the years all authoritative coding sources referred to sepsis and septicemia as the same condition. Finally, in 2008, these coding references stated that sepsis and septicemia are two different conditions:
Sepsis is a body response to dead tissue mediated by the release of
Despite some misconceptions to the contrary, a coder may report angina, unstable (411.1) if a physician documents any of the following diagnoses and a query is not required:
Q:I am looking for help posing queries regarding the specific link between diabetes and conditions typically considered diabetic complications. Should we always query the physician regarding the link between the presenting symptom and the diabetes?
In April, CMS held an ICD-10 conference for software vendors, billing services, and clearinghouses to discuss the ICD-10 and Version 5010 transitions. The goal of the meeting was to openly discuss implementation issues such as testing and resources that to help make the transition easier. The...Read More »
CDI specialists are getting too tied up with the minutiae of ICD-9-CM coding and DRG optimization instead of focusing on the overall clinical picture of the patient and the integrity of the medical record, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, an independent...Read More »