Q: If I document a wound at Stage 3 with no CC or MCC, do I also need to assign a present on admission (POA) status? A: Every diagnosis reported (unless exempt) require a POA status.Read More »
Q: My facility is discussing querying advanced practice providers (APP). Does ACDIS have any official opinion on this? To clarify, the APPs are licensed providers (nurse practitioners, nurse anesthetists, physician assistants, etc., or residents/limited license). I am of the opinion that...Read More »
By Allen Frady, RN-BSN, CCDS, CCS, CRC
On October 1, 845+ codes took effect thanks to the fiscal year 2018 IPPS Final Rule, which was released at the beginning of August. As you review the updates, additions, and deletions in this year’s rule, I wanted to answer some of your...Read More »
Q: If a complication was unavoidable, and has been documented as such, is that good enough reason to not code it? We wouldn’t mark a code as a patient safety indicator if it was an inherent part of the procedure, so would the same hold true for unavoidable complications?...Read More »
Q: I encountered clinical validation issues where documentation noted a diagnosis with criteria, but the criteria used didn't meet the definition. For example, noted sepsis with criteria of tachycardia and increased white blood cell (WBC) count. But, the patient’s heart rate (HR...Read More »
Following ACDIS Radio on January 11, 2016, Timothy Brundage, MD, CCDS, medical director of Brundage Medical Group and a former member of the ACDIS Advisory Board, answered a few more questions relating to...Read More »
Q: I can't distinguish between "code first" and "in diseases classified elsewhere.” Both are used with manifestations and both can't be sequenced as principal diagnosis, and both need etiology codes so what is the difference?