Congestive heart failure (CHF) is one example of a condition for which coders and CDI specialists should understand clinical indicators before querying physicians, says Lynne Spryszak, RN, CCDS, CPC-A, a CDI educator at HCPro, Inc., in Marblehead, MA.
Over the years all authoritative coding sources referred to sepsis and septicemia as the same condition. Finally, in 2008, these coding references stated that sepsis and septicemia are two different conditions:
Sepsis is a body response to dead tissue mediated by the release of
“If you’ve ever read a document that contained convoluted language or gibberish jargon, read on,” a press release from The Center for Plain Language stated. I received that release more than a...Read More »
Q:I have a question about the discharge summary. When a physician documents a firm diagnosis (not probable or suspected) the day before discharge can it be coded as confirmed, or does it need to be documented on the last day/in the discharge...Read More »
Despite some misconceptions to the contrary, a coder may report angina, unstable (411.1) if a physician documents any of the following diagnoses and a query is not required:
