Q:A patient is admitted with an elective colon resection. The physician documents postoperative ileus but then on the day of discharge the notes states: expected postoperative ileus. So do we add the code 997.4 or not?
Q: We had a patient come in for back pain and treatment for a possible neurological impingement. However, after a five-day stay, the physician documents neck mass and for the remainder of the stay the resources appear to have been focused on that treatment. How do I discern the principal...Read More »
Q: What should physicians know now about the level of specificity they’ll be required to document once ICD-10 takes effect? We’re concerned about a potential swell in the number of queries if we don’t begin to address documentation...Read More »
Q: I am very confused about the diagnosis of acute renal injury/acute renal failure. I know that one of the issues is the lack of agreed upon definition of AKI/renal failure and my readings certainly have reinforced this. So, I have the...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 bill was not permitted to be submitted for...Read More »
Q:I have a question about the discharge summary. When a physician documents a firm diagnosis (not probable or suspected) the day before discharge can it be coded as confirmed, or does it need to be documented on the last day/in the discharge...Read More »
