Q: What is the best way to document time spent by physicians performing procedures? The CPT® codes state a vague time amount but the doctors struggle with this.
A: Time is always one of those really fun things, especially with E/M codes, because CPT puts a vague...Read More »
Editor’s note: William Haik, MD, FCCP, CDIP, director of DRG Review, Inc. answered the following questions in conjunction with his webinar, “FY 2017 ICD-10-CM CC/MCC List with Revisions: Clinical Indicators and Query Opportunities.” To purchase the on-demand version...Read More »
Q: Can you please help me determine the query opportunities and code assignment/sequencing argument related to a patient who was admitted with pneumonia, congestive heart failure, acute respiratory failure, and encephalopathy? I thought that the pneumonia would be the primary and the respiratory...Read More »
Q: Why is hospital-acquired pneumonia not considered a CMS hospital-acquired condition (HAC)?
A: This is confusing to a lot of people because of the similarity of terms used. Hospital-acquired pneumonia is a clinical descriptor. However, CMS’ hospital-...Read More »
Q: One of my CDI specialists thought we needed the phrase “unable to clinically determine” as an option on every multiple choice query we send. My take on it is that if we have “other” with an option for free text, that would cover us for compliance. Further, I thought...Read More »
Q: Is it appropriate to code the type of congestive heart failure (CHF) based on the echocardiogram (echo) results? Coding Clinic, Third Quarter, 2014, p. 5, discusses the use of imaging reports for increased specificity. It states that it is appropriate to use imaging...Read More »
Editor’s Note: The ACDIS Conference is only a little over two months away. Over the coming weeks, we’ll take some time to introduce members to a few of this year’s speakers. ...Read More »
