Q: A 79-year-old male nursing home patient presents with lethargy, confusion, and fever after failing an outpatient course of Bactrim for a suspected urinary tract infection (UTI). His white blood count is 22,000, segs 85, bands 10, and blood cultures are negative. He has a temperature...Read More »
Q: Do you recommend carving out time for outpatient [documentation] review, or dedicating someone to this role?
A: We actually carve out time for outpatient review. We started with two initiatives in our ED. One was injections/infusions and documentation...Read More »
Q: I am unsure how “ribs” are categorized in ICD-10. I don’t understand if taking one rib is considered a resection or an excision and why. The coder coded the following record to total ostectomy-rib. If you crosswalk the ICD-9-CM Level 3 code to ICD-10-PCS, it maps to a resection. I...Read More »
Q:Some of our physicians have started documenting “aspiration without pneumonia.” When I questioned one of them about it, he said the patient had acid pulmonary syndrome/Mendelson’s syndrome. When I told the physician that this condition maps to the code for pneumonia,...Read More »
Q:I was wondering what supporting evidence there is for the recommendation to go ahead and link hypertension (HTN) with heart failure as a combination code? The Official Guideline for Coding and Reporting as well as Coding Clinic for ICD-9-CM seems to...Read More »
Q: A consultant has advised us to code only diagnoses listed on the discharge summary. If the diagnosis is not on the discharge summary, the consultant instructed us to query the physician. How do other facilities handle these scenarios?