Most coders and CDI specialists are familiar with the Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis: the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
University of South Alabama (USA) Health System’s Children’s & Women’s Hospital in Mobile planned to begin dual CDI/coding of ICD-10-CM in April. Then came the congressionally mandated implementation delay. Now USA’s dual coding won’t take place until later this fall at the earliest, since...Read More »
Too often an abnormality is an incidental finding, or a lab error and the clinical circumstances, do not support a diagnosis based on that number. Acute hypoxemic respiratory failure can be one of these situations.Read More »
Nutritional issues are not uncommon in children and may have a significant impact on a child’s health. Poor nutrition can negatively affect growth, immune system function, emotions, and long term cognitive development. Poor nutrition can also increase a...Read More »
Facilities have always faced problems related to documentation for cardiorenal syndrome. One major problem with the diagnosis is that CDI specialists may query for clarification of cardiorenal syndrome, but physicians and the CDI staff may not clearly understand how each side defines the term.Read More »
The AHA published its first issue of Coding Clinic for ICD-10-CM and ICD-10-PCS along with its final edition of Coding Clinic for ICD-9-CM. In this Coding Clinic, The AHA editorial board reiterates (on p. 11), that it has no...Read More »
Excisional debridement procedures in the inpatient setting remain under intense scrutiny by Recovery Auditors, Medicare Administrative Contractors (MAC), CERT contractors, and other third-party...Read More »
