MRA Thought of the Day – Avoid an ICD-10 Transition Roadblock: Assess Clinical Documentation Now

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Situation: Let’s begin with two very important ICD-10 readiness true or false questions: Question 1: True or false -Today’s coding professionals will be ready for the ICD-10 transition? Question 2: True or false –Physician documentation will include the necessary detail for accurate and specific ICD-10 code assignment? Response: True -Coding professionals will be ready for the ICD-10 transition on October …

Incidental vs. Complicating?

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

Situation: A 21 year old female is admitted to the hospital with abdominal pain. Testing reveals patient with pelvic inflammatory disease (PID), bacterial vaginosis and a positive pregnancy test. History reveals the patient was sexually assaulted 3 weeks prior and PID likely related to that incident. The patient plans to terminate the pregnancy at Planned Parenthood following discharge and does …

MRA Thought of the Day – Documenting Acuity Clears Up the Confusion

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Situation: On the evening following total hip replacement surgery, the patient is found to be confused and disoriented. The progress notes indicate the patient’s mental status changes are secondary to pain medication, which will be reduced. The PCA pump is removed resulting in the patient’s mental status returning to baseline. Do any of the diagnostic statements require further specification for …

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 …