Q: I am a relatively new CDI specialist in a relatively new CDI program. We learned that we should be examining the health record with an eye toward “what bought the bed.” When we raise this concept to our coders, however, they disagreed with the premise, telling us that such a...Read More »
What is the correct code assignment for a diagnosis of postoperative aspiration pneumonia? ICD-9-CM’s Tabular List under code 997.39 provides the following inclusion terms: “Pneumonia (aspiration) resulting from a procedure.” However, the instructional note under category 997 states, “Use...Read More »
Q: We are struggling with how to query physicians regarding complications of procedures or surgeries. For example, a patient was readmitted for a bile leak two weeks after a cholecystectomy. Neither the attending nor the GI consultant ever stated that this was a complication. Can you...Read More »
Q: We recently had a case where the patient was admitted for “sepsis secondary to a urinary infection (UTI) with chronic Foley.” I am wondering if there is a AHA Coding Clinic for ICD-9-CM tosupport coding this case to 996.64, Infection and inflammatory reaction due to...Read More »
Q: A question was raised by some of the members of my staff regarding the titles of queries. If a query is entitled “Sepsis Query” even if it is an open-ended question is it leading?
A: We must remember that we cannot be leading in our query practice; we...Read More »
Q: I was told that a multiple choice query should have at least four options. Keeping in mind that there may be only one reasonable option in a multiple choice query, what would be a good fourth option for a query about hyperkalemia if the other options are:
