Coding Tip: Getting Control of Root Operation Control

Since the implementation of ICD-10-PCS in 2015, yearly changes have been made regarding the definition of, and guidelines associated with, the root operation Control. This has caused coding professionals much confusion in determining whether to assign a procedure to root operation Control, to assign another root operation, or to not assign a procedure code at all.

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Query Tip: Is Sepsis Present on Admission?

In addition to positive clinical indicators documented at the time of admission, any of these that occur within the few days after admission should also be included. This will support the fact that sepsis could have developed after admission. It is important that a POA query give equal attention to what supports POA yes, as well as POA no to avoid the appearance of a leading query.

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