Q: We are having trouble determining how to assign a code for a pressure ulcer that begins as a Stage I concern that is present on admission (POA) but advances during the patient’s stay to a Stage II or a Stage III. Coding Clinic, Fourth Quarter 2008, p. 194, tells us that even if...Read More »
Q: Can you clarify the expectations related to documenting the discussion between a physician and a CDI specialist when a query is done verbally. The 2013 ACDIS/AHIMA physician query practice brief ...Read More »
Q: In the past few weeks, we noticed physicians are documenting acute congestive heart failure with preserved ejection fraction (EF), instead of diastolic or systolic. In speaking with the physicians, they say the heart failure is not diastolic or systolic. What is the best way...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: Our facility is developing clinical definitions regarding types of atrial fibrillation (afib) given the specificity changes in ICD-10. Could you provide suggestions for these definitions? Do you think is it appropriate to query for persistent atrial fibrillation for the period of more...Read More »
Q: I am looking for additional clarification regarding the recent AHA Coding Clinic for ICD-10-CM/PCS concerning diabetes and the use of the word “with.” While the examples often used in Coding Clinic are specific, the actual...Read More »
Q: As part of an integrated access management program, what medical documents are needed to perform a medical necessity review so that the access care coordinator (ACC) can offer a level of care recommendation to the physician?Read More »
Q:I was reviewing a case with one of our CDI specialists this morning. Briefly, the following clinical indicators documented in the chart are elevated cardiac enzymes, shock, and demand ischemia. Cardiology documented “elevated cardiac enzymes in setting of shock representing a...Read More »
