Q: We recently had a patient who was admitted with sepsis and the physician documented sepsis, a urinary tract infection (UTI) related to chronic Foley catheter, and pneumonia. Can we code sepsis first instead of the complication code? Or is the complication always first? ...Read More »
Q: I’ve heard that, due to the inflammatory response related to septic tissue, perfusion will decrease, and hyperlactatemia and mottling are likely if left untreated. Decreased perfusion means that organs/tissues would get less blood. Is that how mottling (discoloration in irregular...Read More »
Q: I recently heard in a class that the TNM (tumor, nodes, metastasis) system can be used for coding purposes, but I’ve never used it before. As a coding professional, should I know how this system works and how to apply it?Read More »
Last night, I stopped to pick up a few things at Staples. At the checkout counter, the clerk ran into a couple of challenges. None of these interruptions in my checkout experience were this individual’s fault and she handled them while keeping a shy smile and...Read More »
Q:I’ve been told that a patient with the documentation of “traumatic cerebral edema with loss of consciousness of 18 hours and GCS—eyes open to sound,” should be assigned to HCC 166. But I keep coming up with two possible HCCs...Read More »
Lakeyshia Moore, MBA, RHIA, is the senior director of coding and reimbursement at Texas Health Resources in Arlington, Texas. She is a member of the Texas ACDIS local chapter and a member of the 2019 ACDIS Conference Committee.
Q: I’m a bit confused by sepsis sequencing. Should it always be coded as the principal diagnosis, or are there instances where it wouldn’t be principal?
A: If sepsis is present on admission (POA), sepsis (the systemic illness) is coded first, followed by...Read More »
