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?
Q: According to a denial letter, acute metabolic encephalopathy secondary to any disease (which it obviously always is) codes to G94, other disorders of brain in diseases classified elsewhere. The auditor stated to “Please see code category G93.4 which has an excludes 1 note excluding “...Read More »
Q: What should we do about the documentation of “acute pulmonary insufficiency?” What indicators are you using for this in comparison to querying for acute respiratory failure? Acute pulmonary insufficiency is an MCC following surgery but it is also a potential patient safety indicator (...Read More »
Q: When looking at denials timelines, what information should be noted?
A: There are many critical time elements to capture during the denial appeals process. It is recommended that you add these to your denials database. If that is not possible, an...Read More »
Q: What clinical documentation is acceptable to pull Hierarchical Condition Category (HCC) information from for reporting purposes? Would you code from history of present illness, past medical history, active problem list, or the assessment?
Q: If the attending documented, “likely mixed cardiogenic and septic shock,” can I assign codes R57.0 and R65.21?
A: Refer to the documentation within the code book. If you open the book to the R57 code grouping (Shock not elsewhere classified) listed...Read More »
