Tara Bell, MSN, RN, CCDS, CCM, manager of CDI and utilization review services at United Audit Systems, Inc. (UASI) of Cincinnati, worked in CDI for more than 13 years and in nursing for more than 24. For the past several years, she’s gone above and beyond helping the South...Read More »
Q: I have a patient with alcohol-induced pancreatitis. In this case, the documentation notes a lactate level of 2.9 mmol/L with acute kidney injury (AKI). I have always learned that systemic inflammatory response syndrome (SIRS) is defined as two or more of the following...Read More »
Q: I have a question about coding “unspecified” versus “other specified,” as to whether schizophrenia, multiple episodes, acute exacerbation, is coded as schizophrenia, unspecified. The new ICD-10-CM/PCS Official Guidelines for Coding and Reporting do not explain whether paranoid,...Read More »
Q:I’m having problems determining the correct coding guidelines for chronic obstructive pulmonary disease (COPD) and pneumonia. Have the guidelines changed regarding COPD and pneumonia? Do you now have to code the pneumonia as a COPD with a lower respiratory infection...Read More »
Q: On pages 139-140 of the 2016 CDI Pocket Guide, the guidance states that code J95.82 should not be assigned when post procedural respiratory failure is attributed by the provider to a preexisting or other underlying condition. It seems like this statement contradicts...Read More »
Editor’s Note: Timothy Brundage, MD, CCDS, medical director of Brundage Medical Group, LLC, in Redington Beach, Florida, presented on the ...Read More »
Q: Does the provider have to say "acute" exacerbation of COPD or just COPD exacerbation?
A: The best way to figure out the required wording is to take a peek into a code book. If we look at the code J44.1 for COPD exacerbation, you see the word “acute” in parentheses. When words within...Read More »
