Q: We had a patient come in for back pain and treatment for a possible neurological impingement. However, after a five-day stay, the physician documents neck mass and for the remainder of the stay the resources appear to have been focused on that treatment. How do I discern the principal...Read More »
It’s not enough to know whether heart failure is systolic or diastolic. Congestive heart failure (CHF), for example, isn’t an inherent component of systolic and diastolic heart failure, according to Coding Clinic, fourth quarter 2004. That means CHF, when present, requires a second code...Read More »
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?
