Q:Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase “versus” between them? For example, the patient arrives with abdominal pain and the physician orders labs and other tests but they all come back normal. In the discharge note, the...Read More »
Q:Could you please explain unrelated surgical procedure DRGs? For example, a patient with a principal diagnosis of pneumonia whose surgical procedure transurethral resection of the prostate (TURP), MS-DRG 168. Also can you explain how we can differentiate between...Read More »
A diabetic patient is admitted with gangrene. The physician does not specifically link the diabetes and the gangrene, but alsodoes not document any other potential cause of the gangrene. Should you code both conditions?
In ICD-9-CM, coders can assume a cause-and-effect...Read More »
Go to your local bookstore, pick up a copy of Gray’s Anatomy (the book, not the television show), and flip though the illustrations. Alternately, you can Google “Gray’s anatomy illustrations.” They are in the public domain. Some of them are...Read More »
Q:We have a problem getting our physicians to understand what we are querying for (chronic respiratory failure) when a patient is on home oxygen continuously with documented supplementary oxygen (SpO2) of <90% or arterial blood gas (ABG) with hypoxemia documented....Read More »
Q: I need help identifying the principal diagnosis for the following situation. The patient presented with shortness of breath and hypoxia, and had emergent dialysis which resolved his symptoms. However the patient’s international normalized ratio (INR) was sub therapeutic due...Read More »
Q:I am the only CDI specialist in our 150-bed facility. I have held the position for three years, and am the first one to do so helping to build the position from the ground up. Being the only CDI, I am on several committees, responsible for continual physician...Read More »
by Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer
Under the Comprehensive Care for Joint Replacement (CJR), which began April 1, acute care hospitals in selected geographic areas assume quality and payment accountability for retrospectively calculated bundled...Read More »
