Editor’s Note: The following questions were submitted for the ACDIS quarterly conference call of February 14, 2013, and were answered by Donna Wilson, RHIA, CCS, CCDS, Robert Gold, MD, Sylvia Hoffman, RN, CCDS, CCDI, CDIP, and Donald Butler, RN, BSN, of the ACDIS...Read More »
Q: A few times I have seen physicians document Schatzki’s Ring. I understand that if the physician documents “acquired Schatzki’s Ring” that maps to code 530.3 no CC/MCC. However, how would...Read More »
Q:We recently had a case where the patient was admitted for “sepsis secondary to a urinary infection (UTI) with chronic Foley.” I am wondering if there is a AHA Coding Clinic for ICD-9-CM tosupport coding this case to 996.64, Infection and...Read More »
Q: An intoxicated patient comes into the emergency department with a history of alcoholism and the physician prescribes precautions for withdrawal and documents “tremors.” Can we assume that the physician means “delerium tremors” or “DTs”?
Q: I’ve been confused recently regarding coding from the pathology or radiology reports for specificity. It seems that in recent years, (I’ve been coding for 25years) a new interpretation of the coding guidelines has come about. I was taught that as long as a physician with direct...Read More »
Q:The majority of the admissions I am reviewing this week are for an elderly population. It seems that they all have the same admitting diagnoses: Failure to thrive (FTT), urinary tract infection (UTI), fever, dehydration, altered mental status (AMS). I am confused...Read More »
Q: Our physicians frequently document ‘meets sepsis criteria.’ Is this a bad habit forming? If the patient is septic, shouldn’t the physician state sepsis due to, or just sepsis? I worry that if the patient has a few vital signs off the physicians are documenting sepsis...Read More »
Q: I attended the ACDIS conference in Nashville. (It was excellent!) I had a question about whether or not queries can be used to question the documentation of a condition or procedure where the clinical picture in the record does not appear to support a given diagnosis. I thought the...Read More »