Please clarify the rule regarding presumption of the link of diabetes, when documented, to the diagnosis of osteomyelitis when both are documented by the provider.Read More »
Q: We recently admitted a 52-year-old man who was waiting for a liver transplant. He has a history of hepatitis C, chronic back pain, and drug and alcohol abuse. He was found unresponsive at home in a pool of vomit. The toxicology screen on admission was positive for benzodiazepine,...Read More »
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 »
ACDIS Associate Editorial Director Linnea Archibald sends out “missed connections” emails with questions from Council members on a regular basis. Anyone with experience related to one of the questions was invited to respond and Archibald connected them with the question-asker. In order to share...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 »
