MRA Thought of the Day – Right Sided Weakness: Coder and CDS Collaboration Creates a Win-Win Situation

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Situation: A discharge summary reveals the patient’s principal diagnosis to be acute cerebrovascular accident with right sided upper and lower extremity weakness. This diagnostic statement presents two options for the coder: code the symptom as documented or discuss the record with the CDS to determine if a query is warranted for clarification of the weakness. The coder recognizes right sided …

MRA Thought of the Day – E Code Definitions

Cathie Wilde, RHIA, CCS, AHIMA Approved ICD-10-CM/PCS Trainer Coding Leave a Comment

Situation: Sixteen year old male was driving a dirt bike in the woods when he was thrown from the vehicle resulting in an ankle fracture. What would the external cause E code be for the above situation? E821.0? E821.2? Here are my thoughts… Review of the definitions preceding the transport accident E codes located in the ICD-9-CM book provides some …

MRA Thought of the Day – Don’t Be Fooled By Sepsis-Like Features

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Situation: An elderly patient presents with altered mental status and fever. The patient is found to be hypotensive, with a respiratory rate of 22, WBC’s > 12,000 and elevated lactic acid. The documented impression in the history and physical and throughout the progress notes is sepsis like features. For another patient with the same clinical picture, their documented impression might …

MRA Thought of the Day – Contrasting/Comparative Diagnoses

Cathie Wilde, RHIA, CCS, AHIMA Approved ICD-10-CM/PCS Trainer Coding Leave a Comment

Case Scenario: A 90 year old patient is admitted to the hospital with community acquired pneumonia. During the course of hospitalization, the patient develops some aphasia and a stroke is suspected. A CT scan is inconclusive and a MRI is unable to be done as the patient has a pacemaker. The physician signs out the final diagnoses as: community acquired …

MRA Thought of the Day – Think Before You Query

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Situation: Take a moment to think about the physician queries you initiated or thought about initiating this week, specifically, those for abnormal lab results without a documented corresponding diagnosis. An example is a patient that underwent a colectomy; their pre-op HCT was 40 which decreased to 30 postoperatively. The patient was monitored without transfusion. Lab results are casually documented in …

MRA Thought of the Day – Those Pesky Open Wound Infections

Cathie Wilde, RHIA, CCS, AHIMA Approved ICD-10-CM/PCS Trainer Coding Leave a Comment

Scenario: A patient was seen in the ER previously for a foot laceration occurring after stepping on glass while barefoot. The wound was sutured at the time. He now is admitted to the hospital three days later for treatment of foot cellulitis. Question: What is the Principal Diagnosis – complicated open wound or cellulitis? Here are my thoughts… Review of …

MRA Thought of the Day—Discharge Summaries Seal the Deal

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Coding a medical record with incomplete documentation jeopardizes coding accuracy and negatively impacts reimbursement. However, sometimes real world situations prohibit Coding Managers from adhering to best practice standards. In the following scenario the discharge summary provided clarifying documentation; leading to the right diagnosis and reimbursement. A patient with a past medical history of lacunar infarct with residuals presents with facial …

MRA Thought of the Day-Back to the Basics: Coding Conventions

Cathie Wilde, RHIA, CCS, AHIMA Approved ICD-10-CM/PCS Trainer Coding Leave a Comment

A forty-six year old patient arrives in the emergency room with chief complaint of confusion as described by patient’s spouse. A thorough work up is undertaken including blood work, radiological testing and a neurology consult. No etiology for the confusion is identified. The attending physician documents the final diagnosis as “acute confusional state, cause unknown”. Using the encoder, the coder …

MRA Thought of the Day -Clinical Documentation Validation and Coding Compliance

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Situation: Clinical Documentation Improvement Managers (CDIMs) continually monitor the success of their healthcare organization’s CDI program. The metrics they use commonly include volume of queries issued, query success, case mix data, severity of illness, and risk of mortality data. However, there is another critical element that should be monitored by the CDIM: clinical documentation validation.Clinical documentation validation risk assessments should …