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 »
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 »
