Q:I am looking for help posing queries regarding the specific link between diabetes and conditions typically considered diabetic complications. Should we always query the physician regarding the link between the presenting symptom and the diabetes?
In April, CMS held an ICD-10 conference for software vendors, billing services, and clearinghouses to discuss the ICD-10 and Version 5010 transitions. The goal of the meeting was to openly discuss implementation issues such as testing and resources that to help make the transition easier. The...Read More »
CDI specialists are getting too tied up with the minutiae of ICD-9-CM coding and DRG optimization instead of focusing on the overall clinical picture of the patient and the integrity of the medical record, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, an independent...Read More »
I challenge you to find one textbook of medicine, physiology, or pathology that refers to a category of hematologic abnormality as “acute blood loss anemia.”
But coders are very familiar with that term. They may ask a physician whether a...Read More »
A 2007 study in the Journal of the American Medical Association found that direct communication between hospital physicians and primary care physicians occurs infrequently, and that discharge summaries are often times unavailable at the first post-...Read More »
Like many CDI specialists, Janice Davis, RN, clinical documentation analyst at High Point (NC) Regional Health System and her four co-workers struggled with obtaining appropriate documentation for chronic kidney disease (CKD) and acute renal failure (ARF). “So we decided if we listed the...Read More »
Within the Alphabetic Index of ICD-9-CM is a Neoplasm table that assists coders in assigning diagnosis codes (Vols. 1-2). The table is structured based off the specific location of the neoplasm as well as the type of neoplasm. There are four types of neoplasms on the neoplasm table:...Read More »
Every so often, I come across some coding issues that recall other coding issues. I found this situation within the last few weeks and it deserves some discussion.
A baby arrives at the hospital with weight loss....Read More »
