Q: Does sepsis and/or severe sepsis have to be documented in the medical record when only septic shock is noted? We have a couple of physicians that will document septic shock without noting sepsis and/or severe sepsis. I was informed that coding needs to also have the documentation of...Read More »
Q: The revenue officer at our facility says all death charts should have a CC/MCC. I do try to find missed CC/MCCs on the records as well as the complete documentation, however, not all records end up having one. Can you help me understand the basis of this requirement and give me some...Read More »
Q: I have a question about the coding of a Kennedy ulcer. I’ve heard that once an ulcer is identified as a Kennedy ulcer, it should no longer be coded as a pressure ulcer. How do you code a Kennedy ulcer? Or do you not code it at all? A: A Kennedy terminal...Read More »
Q: If the acute respiratory failure is due to pneumonia and the respiratory failure resolves rather quickly, but the patient remains in the hospital for treatment of pneumonia, shouldn’t pneumonia be sequenced as the principal diagnosis? The basis of this question is not solely about...Read More »
Q: Lately, we have been receiving responses of “did not assess or treat” or “this is a chronic stable medical problem not associated with the patient’s presentation,” although the nutritional assessment such as severe malnutrition is...Read More »
Q: If a patient is in a three-tiered DRG, but has a three-day length of stay (LOS), is it correct that the next review need not occur till the LOS equals or exceeds three days? Do we need to capture a possible CC or MCC?
Q: If a consulting physician documents a diagnosis related to his or her specialty but the attending does not (instead simply documenting, “thank you for your assistance”) can the consulting physician’s documentation be used for coding purposes? My most experienced associate says we can...Read More »
Q: A patient was admitted to the emergency department (ED) via ambulance. The emergency medical technician (EMT) noted that the patient was in full cardiac arrest, with ventricular tachycardia (VT). The EMTs shocked the patient via defibrillator en route to hospital. What would we assign...Read More »
