A patient is admitted to the hospital with a diagnosis of pyelonephritis and dehydration. The patient also has a diagnosis of hypertension. While in the hospital the patient suffers a myocardial infarction and has to undergo an angioplasty.
Carolyn works as a coder in a hospital inpatient department. She sees a lab report in a patient's health record that is positive for staph infection; however, there is no mention of staph in the physician's documentation. What should Carolyn do?
Charts are prioritized by attending physician, surgeon, anesthesiologist, and consulting physician. An audit of chart completion showed that the unavailable chart rate was 30% for any given day for surgeons, anesthesiologists, and consulting physicians.
requires two codes to fully describe a single condition that affects multiple body systems, there are other single conditions that also require more than one code.
UHDDS. definitions apply to inpatients in acute care, shortterm, long term care and psychiatric hospital setting. • Since that time the application of the UHDDS. definitions has been expanded to include all nonoutpatient. settings (acute care, short term, long term. care and psychiatric hospitals; home health agencies;
tabular may NEVER be coded without its cause
When you look up this code in the Tabular List, you’ll find the instructional note “Code first underlying neoplasm (C00-D49).”
When you look up this code in the Tabular List, you’ll find an instructional note to “Code also” adrenal adenoma (D35.0-).
Coding for a late effect usually requires two codes.
When we select diagnosis codes for billing, we are telling the story of a patient’s healthcare encounter. Patients often present with multiple conditions — some related, some not. Medical coders are tasked with selecting the most specific codes and putting them in the right order. This code arrangement is called “sequencing,” and it is an essential step to correct coding.
The “Use additional” code note is found below the underlying condition code.
Appears in the Official Guidelines at I.A.7. Codes that are in brackets in the Alphabetic Index are always sequenced second.
This convention instructs that two codes may be required, but it does not provide sequencing direction.
A patient is admitted to the hospital with a diagnosis of pyelonephritis and dehydration. The patient also has a diagnosis of hypertension. While in the hospital the patient suffers a myocardial infarction and has to undergo an angioplasty.
Carolyn works as a coder in a hospital inpatient department. She sees a lab report in a patient's health record that is positive for staph infection; however, there is no mention of staph in the physician's documentation. What should Carolyn do?
Charts are prioritized by attending physician, surgeon, anesthesiologist, and consulting physician. An audit of chart completion showed that the unavailable chart rate was 30% for any given day for surgeons, anesthesiologists, and consulting physicians.