What is the correct principal diagnosis in the following case? A 59-year-old male with history of (h/o)bladder cancer and failure to follow up was admitted for video-assisted thoracic surgery (VAT) for pulmonary nodules found on imaging. The patient had the VAT procedure and a pulmonary wedge...Read More »
There has been a considerable amount of confusion regarding physician terminology, documentation
requirements, and subsequent coding of various diagnostic bronchoscopic lung procedures. Because the current MS-DRG structure categorizes some of...Read More »
While most CDI specialists know to query for conditions related to malnutrition, such as obesity and cachexia, programs frequently ignore dietitians’ documentation and keep dietary professionals out of the coding/querying conversation when they should be partners at the table.Read More »
The American Hospital Association (AHA) does not plan to “convert” past issues of Coding Clinic for ICD-9-CM into new issues for ICD-10-CM/PCS, the AHA confirmed in a CMS teleconference held in November 2011. This decision caused concern...Read More »
In October 2010, when ACDIS first conducted its assessment survey regarding CDI readiness for ICD-10 implementation, 83% of respondents indicated they had no formal ICD-10 training and 44% indicated they had no training timeline (www.hcpro.com/...Read More »
The bane of many CDI specialists’ existence is trying to get physicians to buy into good documentation practices. But a recent notice issued by TrailBlazer Health Enterprises, LLC, put in about as plain words I’ve seen that contractors are now going to be comparing Part A (hospital) with Part B...Read More »
