Did you know that by coding hypertension with associated CKD correctly along with any surgical dialysis access creation on patients admitted with hypertension, will keep the case out of the AHRQ PQI #07: Hypertension Admission Rate quality measure?
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Locating ventilator times were difficult in the paper medical record, but has not become any easier with the implementation on the electronic health record (EHR.) Coders should be encouraged to review the record for exact ventilator times. As mentioned above, this could come down to minutes when selecting the correct ICD-10-PCS code.
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Procedure code assignment for excisional debridement has always been a focus area in coding audits. The biggest concern is whether or not the debridement is truly excisional in nature, and if the documentation truly supports an excisional debridement. HIA has written a previous Coding Tip on determining nonexcisional vs excisional debridement.
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How does a coder sequence COPD and pneumonia? As of October 1, 2017 the note under the code J44.0 COPD (chronic obstructive pulmonary disease, with acute lower respiratory infection) was changed from “Use additional code to identify infection” to “Code also to identify the infection”. A “code also” note does NOT give a sequencing directive as the “use additional code” does. The PDX should be assigned based on the circumstances of the admission. Below are some examples that may help you determine the PDX when COPD and pneumonia are both present and responsible for the admission.
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COPD is a chronic inflammatory lung disease that causes obstructed flow of air from the lungs. The disease is progressive in nature and typically will worsen over time. The most common cause of COPD is smoking tobacco. COPD is increasingly being used to document lung disease. The coder must review the record for further specificity of the…
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