Q:Some of our physicians have started documenting “aspiration without pneumonia.” When I questioned one of them about it, he said the patient had acid pulmonary syndrome/Mendelson’s syndrome. When I told the physician that this condition maps to the code for pneumonia,...Read More »
Many CDI specialists don’t spend a lot of time working with obstetric (OB) records, or may even ignore them altogether, principally because of the ICD-9-CM Chapter 11 coding guideline that basically says that pregnancy overrides...Read More »
A patient’s medical record contains a wealth of information about his or her hospital encounter, including diagnoses, treatments, operative reports, and ancillary notes. Unfortunately, much of the detailed information found in a patient record is...Read More »
I’m an old (and I do mean OLD) ICU nurse. As a working nurse, my relationships with physicians usually centered on getting them to listen to my assessments: Yes, you need to get out of bed and come see this patient who has stopped...Read More »
The length of stay (LOS) for coronary artery bypass graft patients and valve replacement patients at York Hospital (YH)/ Wellspan Health was significantly higher than the Medicare geometric mean length of stay (GMLOS) according to results of a record...Read More »
Q:I was wondering what supporting evidence there is for the recommendation to go ahead and link hypertension (HTN) with heart failure as a combination code? The Official Guideline for Coding and Reporting as well as Coding Clinic for ICD-9-CM seems to...Read More »
