Q: Do you have any suggestions for when a clinical validation query is sent for sepsis asking for additional supporting documentation if ruled in? We are seeing providers rule sepsis in as a valid diagnosis, but they do not provide additional supporting documentation. We seem to be...Read More »
Q: What is a neobladder reconstruction and how is this procedure reported in ICD-10-PCS?
A: Neobladder reconstruction is the surgical construction of a new bladder using intestinal tissue. This surgery may be performed if a patient has...Read More »
Q: Please advise on the coding guidelines in ICD-10-CM regarding the coding of fractures and their specificity obtained from a radiology report. For example, a patient is diagnosed with ankle sprain but when...Read More »
Q: When you have a patient admitted for observation and then changed to inpatient, do you use the diagnosis that makes them meet inpatient criteria as your primary diagnosis or the observation diagnosis?
Q: Does your facility currently abide by any policies when it comes to coding ‘obesity’ and/or ‘morbid obesity’ in terms of requirements for the provider to document how the diagnosis has met the Uniform Hospital Discharge Data Set (UHDDS) definition of ‘monitoring, evaluating,...Read More »
Q: Does documentation for a drug or alcohol use disorder need to specifically state “in remission,” or is a history of drug use sufficient to classify the condition as in remission?
A: Effective October 1, 2022, coders will find the following new ICD-10-...Read More »