This is a classic documentation opportunity to clarify “volume/fluid overload,” says Lynne Spryszak, RN, CPC-A, CCDS, CDI education director for HCPro, Inc., in Danvers, MA. “If the physician hasn’t documented acute CHF, I would hesitate to ask for this condition based on this mild BNP elevation...Read More »
Q: A 79-year-old male nursing home patient presents with lethargy, confusion, and fever after failing an outpatient course of Bactrim for a suspected urinary tract infection (UTI). His white blood count is 22,000, segs 85, bands 10, and blood cultures are negative. He has a temperature...Read More »
Q: Do you recommend carving out time for outpatient [documentation] review, or dedicating someone to this role?
A: We actually carve out time for outpatient review. We started with two initiatives in our ED. One was injections/infusions and documentation...Read More »
Q: I am unsure how “ribs” are categorized in ICD-10. I don’t understand if taking one rib is considered a resection or an excision and why. The coder coded the following record to total ostectomy-rib. If you crosswalk the ICD-9-CM Level 3 code to ICD-10-PCS, it maps to a resection. I...Read More »
Q:Some of our physicians have started documenting “aspiration without pneumonia.” When I questioned one of them about it, he said the patient had acid pulmonary syndrome/Mendelson’s syndrome. When I told the physician that this condition maps to the code for pneumonia,...Read More »
Q:I was wondering what supporting evidence there is for the recommendation to go ahead and link hypertension (HTN) with heart failure as a combination code? The Official Guideline for Coding and Reporting as well as Coding Clinic for ICD-9-CM seems to...Read More »
