Editor’s Note: AHA Coding Clinic for ICD-9-CM released its second round of ICD-10 coding guidance in its First Quarter 2013 issue. HCPro CDI Education Director Cheryl Ericson, MS, RN, CCDS, CDIP, says the guidance contains information regarding diagnosis clarification,...Read More »
Q:I realize that if the body mass index (BMI) of a patient is documented by nurses and dieticians can be coded if the physician documents the clinical significance (i.e. morbid obesity). However, if the BMI is documented by a patient care tech or nursing ward secretary...Read More »
Current SIRS criteria are insufficient, confusing, and don't indicate whether a patient is truly sick, says Robert S. Gold, MD, founder and CEO of DCBA, Inc., in Atlanta.
Some patients—particularly those who are critically ill—may meet necessary criteria for SIRS and truly have...Read More »
A delay in ICD-10’s implementation has definitely caused angst, especially for coding staff, says Gloryanne Bryant, RHIA, CCS, CDIP, CCDS, regional managing director of HIM, NCAL revenue cycle, at Kaiser Foundation Health Plan, Inc. & Hospitals in Oakland, Calif. “I think...Read More »
Q: What are the pros/cons of coding ‘hepatic encephalopathy’ as a secondary condition? For example, here is a clinical scenario that happened at our facility: A patient is admitted for pneumonia and the history and physical (H&P) states the patient has a ‘history of...Read More »
CMS’ three-day rule defines certain preadmission services as inpatient operating costs, meaning they are bundled and billed as part of the inpatient claim and payment is made as part of the applicable DRG payment for the case. This sounds simple, and there had been very little new guidance for...Read More »
The ICD-9-CM guidelines state that it’s unusual for two or more diagnoses to meet the definition of principal diagnosis. However, coders know this isn’t exactly true, as the scenario tends to occur frequently.
Pneumonia and heart failure is a common combination with which patients...Read More »
