As the role of coded data expands beyond statistical reporting and DRGs to accurate depictions of clinical scenarios, it’s becoming increasingly difficult to determine when a condition reaches a reportable threshold, according to a new ACDIS White Paper “...Read More »
Carolinas Healthcare System (CHS) agreed to pay $6.5 million to settle allegations of a years-long practice of upcoding urine drug tests, the Office of...Read More »
Q: A patient with documented acute respiratory failure, could have both confusion and somnolence, but should both confusion and somnolence be coded? When should the symptoms be coded? For example, with a patient who has abdominal pain...Read More »
CMS introduced 3,562 new ICD-10-PCS codes, 1,821 revised titles, and deleted 646 codes. These changes amount to a total of 78,705 codes in the 2018 code set, while the 2017 code set contained only 75,789 codes.Read More »
Q: If the principal diagnosis is pneumonia, do I need to also code the symptom dyspnea? Or, is the dyspnea integral to the pneumonia? A: If the dyspnea (and as other...Read More »
Q: If a patient is admitted for anemia related to a malignancy and is treated only for anemia, the principal diagnosis goes to the malignancy. I understand that the malignancy was the root cause of the condition making it the principal...Read More »
Though many coders and auditors say so, there is no official direction that states diagnoses can only be reported if they’re included in the discharge summary. We teach in our CDI Boot Camps that, although it’s desirable if the...Read More »
CMS released a change request May 30 describing changes which will be implemented in the July 2017 quarterly update to the outpatient prospective payment system (OPPS...Read More »
