ICD-9 guidelines indicate that coders should not report routine or expected postoperative pain that occurs immediately after surgery. Differentiating between postoperative pain and pain that occurs during the postoperative period is important, says Kathy DeVault, RHIA, CCS, CCS-P,...Read More »
A clear understanding of the definition of principal diagnosis and the factors that play into principal diagnosis selection is extremely important, although oftentimes confusing. The definition of principal diagnosis is the diagnosis that is established after study to be the chief reason...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 »
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 »
