Q: We have a patient who is diagnosed as having acute renal insufficiency due to dehydration with decreased urinary output and was admitted for IV hydration. What diagnosis codes should we assign?
CMS and the National Center for Health Statistics recently released the 2019 ICD-10-CM Official Guidelines for Coding and Reporting. Changes include clarification on the usage of “with,” updated sepsis guidance, and added guidelines for subsequent myocardial infarction.
Q: In what instance would septic shock not be coded as a principal diagnosis (PDX)? I’ve been under the impression that septic shock should always be reported as a PDX.
Adriane Martin, DO, FACOS, CCDS, says that knowledge of coding guidelines and Coding Clinic advice, as well as an understanding of the spine anatomy and the spinal fusion procedure itself, can go a long way toward helping put together the pieces of the fusion puzzle.
Chris Simons, MS, RHIA, details way to improve querying across health information management (HIM), coding, and CDI departments since querying providers is a key strategy for improving documentation. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Amy Sanderson, MD, says that the term “dysphagia” has many synonyms used by providers in medical documentation. However, not all of these symptoms are able to describe the diagnosis with enough specificity so that it can be translated into its corresponding code assignment.
Q: Our coding team is currently debating how to report acute tubular necrosis (ATN) in ICD-10-CM for a patient after a renal transplant. Can you provide any guidance?
In June, an article detailing the upcoming release of the fourth edition of the universal definition of myocardial infarction (MI) was published in the American Journal of Medicine .
William E. Haik, MD, FCCP, CDIP , AHIMA-approved ICD-10-CM/PCS trainer, Jonathan Besler, CPA, MA , and Mary Devine, RN , write that while it is well-known that ICD-10-CM/PCS code assignment impacts hospital reimbursement and compliance, there is an additional code that often flies under the radar for inpatient coders and has a huge impact on reimbursement: the discharge status code.