With all of the attention around the increased specificity of ICD-10-CM codes, facilities are concerned that documentation will lack sufficient detail. And as CDI specialists know, physicians don’t always provide enough information for coders to choose the most specific ICD-9-CM code.
Q:My question has to do with coding guidelines regarding secondary diagnosis followed by contrasting/comparative diagnoses. Let me explain a particular scenario. This was a two-day stay over the weekend. The patient was admitted for further evaluation with a history and...Read More »
Determining when to seek clarification regarding patients with altered mental status can be tricky business. Patients who already have established dementia and are now off their baseline with an acute metabolic disorder such as UTI, physicians are typically...Read More »
Most coders know that reporting a complication of care requires that the medical record include explicit documentation of the relationship between the condition and the procedure. Previous versions of the ICD-9-CM guidelines include this requirement in Chapter 17 (Injury and Poisoning),...Read More »
Q: Should we query for the specific pulmonary exacerbation of cystic fibrosis (CF)? Coding Clinic states that the exacerbation of CF should be listed first.
A: ICD-9-CM codes for CF (i.e., 277.00-277.03) are combination codes. ICD-9-CM code 277....Read More »
Q:A patient with a long history of Type I diabetes is admitted after a syncopal episode. Urine culture grows greater than 100,000 E. coli, and the physician documents a diagnosis of urinary tract infection (UTI) treated with PO Bactrim. If the physician documents the...Read More »
ICD-10-CM/PCS incorporates laterality, acuity, anatomical specificity, and a slew of additional combination and complication codes. Who will submit queries when this information is missing in a medical record? Will coders or CDI specialists take on this role? Perhaps it might be a combination of...Read More »
