Q:Some of our physicians have started documenting “aspiration without pneumonia.” When I questioned one of them about it, he said the patient had acid pulmonary syndrome/Mendelson’s syndrome. When I told the physician that this condition maps to the code for pneumonia,...Read More »
Many CDI specialists don’t spend a lot of time working with obstetric (OB) records, or may even ignore them altogether, principally because of the ICD-9-CM Chapter 11 coding guideline that basically says that pregnancy overrides...Read More »
The length of stay (LOS) for coronary artery bypass graft patients and valve replacement patients at York Hospital (YH)/ Wellspan Health was significantly higher than the Medicare geometric mean length of stay (GMLOS) according to results of a record...Read More »
Q:I was wondering what supporting evidence there is for the recommendation to go ahead and link hypertension (HTN) with heart failure as a combination code? The Official Guideline for Coding and Reporting as well as Coding Clinic for ICD-9-CM seems to...Read More »
Q: A consultant has advised us to code only diagnoses listed on the discharge summary. If the diagnosis is not on the discharge summary, the consultant instructed us to query the physician. How do other facilities handle these scenarios?
by Joel Moorhead, MD, PhD, CPC, and Diana Williams, BS, CPC, CCS-P, CPMA
The ICD-9 chapter-specific guidelines for neoplasms (Section 1.C.2) provides guidance for coding and sequencing of complications associated with malignancies. This section in the ICD-9-CM Manual ...Read More »
