Q: If the radiology or pathology report stated ovarian cancer but the physician never documented an ovarian mass, is it true you can’t use a present on admission (POA) query to capture the ovarian cancer because the physician made no reference to it? Would you need to use either an...Read More »
by Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC
The beginning of March brought us the release of the first quarter 2023 Coding Clinic. This release is short (only 39 pages) and brought forth little in surprises. That is a good thing!
Q: I have a question regarding acute organ dysfunction. If a provider documents “hyperbilirubinemia related to severe sepsis with acute organ dysfunction,” will this suffice for coding acute organ dysfunction, or should I query for a more definite diagnosis?
Cardiac arrest during labor and delivery appears more common in more recent years but with better survival rates, according to a national study recently published in the Annals of Internal Medicine. The findings showed this...Read More »
Q: We recently had a patient who presented with a stage 2 pressure ulcer. Due to hypoperfusion, the pressure ulcer progressed. The physicians are now documenting progression due to “skin failure” due to hypoperfusion. Can you have skin failure at the same site of a pressure ulcer, or...Read More »
