This month’s question was submitted on July 31, 2023, and focuses on the proper DRG classification for transcatheter aortic valve replacement (TAVR) with MCCs. Please note that the questions and answers have been de-identified for the purposes of this article.
Q:I know that in an inpatient setting coders are allowed to use suspected diagnosis when a definitive diagnosis cannot be determined. However, we have had some trouble with physicians using the term “rule out” or “differential diagnosis”...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: AHIMA’s 2008 practice brief, “Managing an Effective Query Process,” appears to allow the initiation of post-bill queries as a result of an audit or other internal monitor. Historically we believed that a query completed after the initial...Read More »
Q: Since Acute Renal Failure (ARF) is no longer a MCC (as of October 1, 2010). I would like some input on how facilities have coped with the change. Do you just code ARF, or have you started querying physicians for more specific information such as documentation for acute...Read More »
Q: Some physicians are uncomfortable making addendums to the discharge summary to include the pathological findings (e.g., malignancy). Instead, they dictate a tumor board note to summarize the course of treatment and final pathological diagnosis. However, the tumor board note is usually dated...Read More »
