Q: I work at a pediatric hospital and am wondering if a newly diagnosed diabetic patient should also have malnutrition coded separately. While the dietician sees these patients routinely, the head of endocrinology explained she hasn’t been documenting the level of malnutrition because it...Read More »
Q: We are struggling with coders querying certain diagnosis because they feel there is conflicting documentation in the record, and then we are “losing” that diagnosis. For example, the physician documents acute respiratory failure a couple of...Read More »
Q:A patient presented to the hospital for a coronary artery bypass graph (CABG) and stage 4 chronic kidney disease (CKD). After surgery, the physician documented additional kidney damage, end stage renal disease (ESRD), and dialysis. ESRD is a MCC, however, the coder thinks...Read More »
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 »
