Q:Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase “versus” between them? For example, the patient arrives with abdominal pain and the physician orders labs and other tests but they all come back normal. In the discharge note, the...Read More »
Editor’s Note: Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, MCP, presents “Integrating CDI processes with the EHR: Getting it right from the beginning,” on Tuesday, May 22 at 3:15 p.m., in Track 7, Leadership and Department Management. The follow Q&A was conducted by ACDIS Member...Read More »
Q:Could you please explain unrelated surgical procedure DRGs? For example, a patient with a principal diagnosis of pneumonia whose surgical procedure transurethral resection of the prostate (TURP), MS-DRG 168. Also can you explain how we can differentiate between...Read More »
Q: I realize that if the body mass index (BMI) of a patient is documented by nurses and dieticians, it can be coded if the physician documents the clinical significance (i.e., morbid obesity). However, if the BMI is documented by a patient care tech or nursing ward secretary in...Read More »
