Operative reports can be a gold mine of information, far surpassing often vague or generalized progress notes, but sometimes this resource is left completely untapped, says Lynne Spryszak, RN,CPC-A, CCDS. Coders know they should review the complete operative report before coding...Read More »
In March 2008, the National Kidney Foundation sent a letter to the National Centers for Health Statistics and asked that the term “acute kidney injury” (AKI) be an optional phrase for assigning...Read More »
Q: Is systemic inflammatory response syndrome (SIRS) an inherent part of an infection? For example, when a patient comes in with pneumonia, and clinical indicators are present for SIRS but the physician did not specifically write SIRS, should coders or CDI specialists query physicians?...Read More »
Q:A patient is admitted with an elective colon resection. The physician documents postoperative ileus but then on the day of discharge the notes states: expected postoperative ileus. So do we add the code 997.4 or not?
It may be too early to start intensive ICD-10-CM training for your coding and CDI team, but now is a good time to at least become familiar with features of the new system.
During CMS’ Basic Introduction to ICD-10-CM National Provider Call held earlier this year, Sue...Read More »
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 »
