Coding and CDI Tips
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Coding and CDI Tips
Coding Corner Tips: Dural Tear Clarification
Dural Tear Clarification Per Coding Clinic, First Quarter 2024: A dural tear is clinically significant and should always be reported when documented by the provider. G97.41, accidental puncture or laceration of dura during a procedure is a CC...
CDI Tips & Friendly Reminders: Atrial Fibrillation (AF)
Atrial Fibrillation (AF) Paroxysmal AF Definition: Episodes terminate either spontaneously or with treatment within 7 days; may recur Persistent AF Definition: AF is continuous and lasts > 7 days, fails to terminate spontaneously Long-standing Persistent AF...
Coding Corner Tips: Myocardial Infarction with Angina
Myocardial Infarction with Angina Per Coding Clinic, First Quarter 2024: Is it appropriate to assign a code for CAD with angina for the severe native multi-vessel disease that resulted in the MI? Examples: Assign code I21.4: Non-ST elevation (NSTEMI) myocardial...
Coding Corner Tips: Underdosing
UnderdosingPer Coding Clinic, First Quarter 2024: Underdosing when a PRN medication is not taken Example: Documentation states: A patient presents to the ED with shortness of breath due to an exacerbation of asthma. The patient did not take his PRN medication,...
CDI Tips & Friendly Reminders: Debridement
Debridement Excisional Debridement Definition: The surgical removal or cutting away of devitalized tissue, necrosis, and slough. Non-Excisional Debridement Definition: The nonoperative brushing, irrigating, scrubbing, or washing of devitalized tissue, necrosis,...
CDI Tips & Friendly Reminders: Coma
ComaDefinition: Deep state of unconsciousness where patients are unable to move or be aware of or respond to their surroundings with loss of thinking abilities however retain non-cognitive function and normal sleep patterns.Diagnostic CriteriaA comprehensive...