Documentation improvement staff often struggle with principal diagnosis selection. A clear understanding of the definition of principal diagnosis and the factors that play into principal diagnosis selection is extremely important, although often confusing.
One of the most confusing diagnoses to code and sequence is the acute myocardial infarction (AMI). It is the elephant in the room of circulatory diagnoses—it takes up the most space and can never be ignored. I’m going to try to make some...Read More »
ICD-10-PCS codes include one digit for the root operation that the provider performs. The root operation is always the third character in the seven-character code. The definitions of these root operations are consistent across other sections of ICD-10-PCS, although they may be represented by...Read More »
Q: Recently I have discussed the BMI and malnutrition status on patients with our Registered Dieticians (RD). The question arose as to where our criteria came from. I understand that the...Read More »
Many cases exist in which CDI specialists need to query physicians to clarify the use of the term “history.” Consider the following situation in which a physician admits a patient with pyelonephritis. The past history states right lower lobe lung carcinoma proximal lesion. ...Read More »
Q: I am wondering about whether coders can use information the physician takes from test results and includes in the history and physical (H&P). We recently had a situation where the H&P indicated under the studies section that “chest x-ray showed atelectasis,” or “EKG showed...Read More »
The more I learn about ICD-10, the more worried I get. At this point my worries are more related to knowing enough to be dangerous but not knowing nearly enough to truly understand or feel confident about our CDI program’s preparation efforts. Two...Read More »
This month’s question was submitted on July 31, 2023, and focuses on the proper DRG classification for transcatheter aortic valve replacement (TAVR) with MCCs. Please note that the questions and answers have been de-identified for the purposes of this article.
