Q: In the past few weeks, we noticed physicians are documenting acute congestive heart failure with preserved ejection fraction (EF), instead of diastolic or systolic. In speaking with the physicians, they say the heart failure is not diastolic or systolic. What is the best way...Read More »
Q:I can’t distinguish between “code first” and “in diseases classified elsewhere.” Both are used with manifestations and both can’t be sequenced as principal diagnosis, and both need etiology codes so what is the difference?
Q: Our facility is developing clinical definitions regarding types of atrial fibrillation (afib) given the specificity changes in ICD-10. Could you provide suggestions for these definitions? Do you think is it appropriate to query for persistent atrial fibrillation for the period of more...Read More »
Q: I am looking for additional clarification regarding the recent AHA Coding Clinic for ICD-10-CM/PCS concerning diabetes and the use of the word “with.” While the examples often used in Coding Clinic are specific, the actual...Read More »
Q: As part of an integrated access management program, what medical documents are needed to perform a medical necessity review so that the access care coordinator (ACC) can offer a level of care recommendation to the physician?Read More »
Q:I was reviewing a case with one of our CDI specialists this morning. Briefly, the following clinical indicators documented in the chart are elevated cardiac enzymes, shock, and demand ischemia. Cardiology documented “elevated cardiac enzymes in setting of shock representing a...Read More »
Q:We are getting pressure from our othopods to send all queries to their nurse practitioner (NP). Our facility bylaws allow NPs to function independently and they are allowed to answer queries without co-signature, so we routinely send queries to NPs who are caring for...Read More »
Q: We have a teenager with systemic lupus erythematosus (SLE) and history of lupus nephritis who came into the ED with seizures. The physician admitted the patient with documentation of with status epilepticus and hypertensive urgency. The intensivists then documented hypertensive encephalopathy...Read More »
