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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,...
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,...
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...
New Codes for Sickle Cell Disease with Dactylitis (Valid for October 1, 2023 discharges)• D57.04 Hb-SS disease with dactylitis• D57.214 Sickle-cell/Hb-C disease with dactylitis• D57.414 Sickle-cell thalassemia, unspecified, with dactylitis• D57.434 Sickle-cell...
Complication Comorbidity UpdateSocial Determinants of Health (SDOH) codes Z59.00, Homelessness unspecified, Z59.01, Sheltered homelessness and Z59.02, Unsheltered homelessness will be considered CC’s (complication/comorbidity) beginning with October 1, 2023...
Pathological FracturesDefinition: A bone fracture that occurs without adequate trauma, caused by an underlying disease.Diagnostic CriteriaIdentified in Radiology/Diagnostic Imaging such as X-Ray, CT, MRI, or bone scans. There are various underlying causes for...
New Code for Resistant Hypertension (Valid for October 1, 2023 discharges)I1A.0 Resistant hypertension May be documented as: Apparent treatment resistant hypertension, Treatment resistant hypertension, True resistant hypertension. The ICD-10-CM Tabular instruction...
Hypertensive CrisisDefinition: HTN: Systolic blood pressure (SBP) of 130mm Hg or more and/or diastolic blood pressure (DBP) of more than 80mm Hg HTN Crisis: Generic term to describe hypertensive urgency or hypertensive emergency, typically seen with elevated blood...
Medicare Advantage is on the brink of a significant restructuring as it transitions from V24 to V28 of the hierarchical condition categories (HCCs) risk adjustment model. In a recent Journal of AHIMA article, I partnered with Jeanie Heck, BBA, CCS, Education...
Respiratory FailureDefinition: Syndrome where the respiratory systems fail in either or both the gas exchange function or oxygenation and carbon dioxide elimination. Recognized as either hypoxemic or hypercapnic.Coding Considerations:Review the circumstances of...
Poisonings vs. Adverse Reactions vs. Toxic Effects vs. Underdosing DefinitionPoisoning: reaction to the improper use of a medication. This can include either:Wrong substanceWrong doseWrong personWrong Route of administrationTaken in combination of alcohol, illicit...
Exagamglogene autotemcel (Exa-cel) (aka CTX001™) is a genetically modified cell therapy that is used to increase fetal hemoglobin (HbF) in patients with sickle-cell disease (SCD) and transfusion-dependent beta-thalassemia (TDT). Exagamglogene autotemcel is an...