Question: I am a little confused regarding the meaning “clinically undetermined” or “unable to determine” as a query choice. If a physician chooses unable to determine, does it mean the provider disagrees with the presented choices or disagrees with a diagnosis entirely? For example...Read More »
Q: If the radiology or pathology report stated ovarian cancer but the physician never documented an ovarian mass, is it true you can’t use a present on admission (POA) query to capture the ovarian cancer because the physician made no reference to it? Would you need to use either an...Read More »
by Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC
The beginning of March brought us the release of the first quarter 2023 Coding Clinic. This release is short (only 39 pages) and brought forth little in surprises. That is a good thing!
Q: I have a question regarding acute organ dysfunction. If a provider documents “hyperbilirubinemia related to severe sepsis with acute organ dysfunction,” will this suffice for coding acute organ dysfunction, or should I query for a more definite diagnosis?